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The Hoi ^0 It
Psychiatric LilDrary
/ ^^^
Sig^mi
The Holsholt
Psychiatric Library
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!L#&aitsi
The HolahDlt
Psychiatric Library
A
THE
TECHNIQUE OF POST-MORTEM
EXAMINATION
AAA
BY
LUPVIG H,EKTOEN, M. D.
PATHOLOGIST TO THE COOK COUNTY HOSPITAL, CHICAGO,
PROFESSOR OF PATHOLOGIC ANATOMY IN THE COLLEGE OF PHYSICIANS AND
SURGfeONS OF CHICAGO
Wig'H:^ p{i*i»Y-(J)NE:IttiiJ5WA3gotJs •. .•
• • ••• •• • • ••• • •• • • ••* ••
• •••••• • ••*•• *•••• •
• •• •• •••• ••••••*• •• •• • •
CHICAGO
THE W. T. KEENER COMPANY
1894
Copyrighted 1893
BY
THE W. T. KEENER CO.
► • ••
• • 2 •
•
••• *
• • •
• •
• •
• • a
• ••
•• «
• •
• •• «
* • •
• • •
• • •
• • •
• • •
• •
•..: :
•• •
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• • •
• •
• •
> • • (
* • • •
• • • • •
Hl7
PREFACE.
In the following pagaa the subject of post-mortem
examination has been considered with especial reference
to the technique.
The systematic and minute consideration of the
various appearances and the diagnosis of pathologic
changes in the fresh organs has been purposely
avoided, and only such general and comprehensive
statements have been made in this direction as were
necessary to emphasize the value of the various prac-
tical details.
The little book has been prepared particularly for
the guidance of the medical students who frequent the
demonstrations in pathologic anatomy given by the
author at the Cook County Hospital in Chicago ; it is
also thought that the total absence in this country of
statutory regulations to guide and direct the practi-
tioner in medico-legal cases will serve to extend its
usefulness, especially as the subject will be considered
somewhat more in detail than is the case in the com-
prehensive text-books of pathologic anatomy and
medical jurisprudence.
Ill
50055
iv Preface
Among the various writings dealing with this sub-
ject that have been consulted, particular reference
should be made to those of the following authors:
Virchow, Orfch, Nauwerck, Delafield and Prudden,
Blackburn and D. J. Hamilton.
My thanks are due for aid and advice in various
ways to Dr. Louis J. Mitchell, Dr. Weller Van Hook,
Dr. A. Gehrman, Dr. Adolph Meyer and Mr. Gayton
A. Douglas.
LuDviG Hektoen
CONTENTS
PAGE
Genebal Considebations *.
Introdaotion 1
The Room, the Table, General Convenienoes 2
The Time after Death for the Autopsy 4
Embalmed and Frozen Bodies 5
The Record 7
Sample of Report of Post-Mortem Examination to
the Coroner 13
Early Steps in the Preparation of Post-Mortem Ma-
terial for Microscopic and Bacteriologic Purposes 15
Post-Mortem Dissection Wounds 26
Statistical 29
Special Instruments and Appliances 30
Examination of the Body
Inspection 38
The Order of the Internal Examination 43
The Spinal Canal 46
The Spinal Cord 48
The Coverings of the Cranial Cavity 61
Removal and External Examination of the Brain ... 68
Section of the Brain 62
The Base of the Skull 76
The Orbits 76
The Ears 76
V
vi Contents
The Nasal Cavity and Naso-Pharynx 78
The Face 80
The Long Anterior Incision of the Trank 80
Inspection of the Abdomen. 84
Opening the Chest 86
Inspection of the Chest Cavities 87
The Pericardinm 88
The Heart 89
The PienrsB and the Lungs 104
The Neck and its Organs 110
Removal of Organs of Neck and Chest in Toto 116
The Abdominal Cavity 117
The Omentum 118
The Peritoneum 119
The Spleen 119
The Adrenals and the Kidneys 120
The Pelvic Viscera 127
The Mesentery and the Intestines 134
The Common Bile Duct and the Portal Vein 139
The Liver and the Gall Bladder 141
The Stomach and the Duodenum 144
The Pancreas 147
The Semilunar Ganglia 147
Aorta, Vena Cava, Thoracic Duct, Retroperitoneal
Glands 148
The Extremities 149
Examination in Cases of Suspected Poisoning 152
Examination of New-Bobn CniiiDBEN 156
Restobation of the Body 165
LIST OF ILLUSTRATIONS
• UnvnUiiij; Poit-motteoi Table with Conoave, Per-
riiraled Sarfsoe
[iHI? witb Mdller'a Fluid ooiitainiDg pieoas from
ti Kiduej and Lang
tpt Knife
s-eaged Brain Knife
^rly made Knterotome with smooth projeo-
~ ttm
)tieTlj (SonBtrnctad Enterotome with sharp
Jfcwfc
rwitt rounded Blade (or sawiag Vertebral
il Rhaohitome
a ChiBBl
i ChieelB
e Mallet
f Baet-tsBtBr'a Qlaas
t GrsduRted Cone (Hamilton)
I Removal of Calvaria; the Dnra over the right
Hemisphere refleoted on the left
15 Pick's Myelotom
1i> Section of the Brain b; VIrobow's method (Nan-
nerob) facing
IT SectloQ of tbe Brain by Virohov's method (Nan-
werok) facing
IH Ferpendionlar TransverBe Section of Hnmnn Brain
Section III (Hamilton)
1 t
vi Contents
The Nasal Cavity and Naso-Pharynx
The Face
The Long Anterior Incision of the Trunk
Inspection of the Abdomen
Opening the Chest
Inspection of the Chest Cavities
The Pericardium
The Heart
The Pieurte and the Lungs I ' ■ ♦
The Neck and its Organs 1 • •
Removal of Organs of Neck and Chest in Toto It
The Abdominal Cavity
The Omentum
The Peritoneum
The Spleen
The Adrenals and the Kidneys
The Pelvic Viscera
The Mesentery and the Intestines
The Common Bile Duct and the Portal Vein
The Liver and the GaU Bladder
The Stomach and the Duodenum 1 -
The Pancreas P
The Semilunar Ganglia I
Aorta, Vena Cava, Thoracic Duct, Retroperitoneal
OlandB i
The BxtremitieB I {'•'
■DIAXIOH x> Gabsb of Suspkcted Poisoning 1 . •
UIATXOH or Nkw-Bobn Childben 1 .'
BATIOW or THB BODY 1 t'l.'i
I ■> ■
THE TECHNIQUE OF POST-MORTEM
EXAMINATION.
GENERAL CONSIDERATIONS.
INTRODUCTION.
Accuracy of observation, completeness of detail,
and sound conclusions can be obtained only when the
post-mortem examination is made according to some
definite and systematic plan so that regions and organs
-are successively examined without disturbing the rela-
tions and appearances of structures yet to be investi-
gated.
In order to insure the improved results which such
a mode of procedure brings, many European govern-
ments prescribe in statutory rules and regulations the
exact order to be followed in all medico-legal investi-
gations. In this country such matters are left in the
hands of the individual physician without a word of
instruction. Consequently the course of justice is
more likely to meet with serious obstacles in blunder-
ing and defective examinations after death, and medical
literature contains many examples of unnecessarily im-
perfect and incomplete autopsies that leave important
pathologic questions undecided and encourage false
conclusions.
1
'i The Techniijce of Post-Mohtem Esaminatiu:
Tlie wanton waste of Viilnable pathologic niaten
in many hospitals and public iBstitutiona at the present
time, on accouut of defective esamination and imjier-
fect record-keeping, i-eflects seriously upon the scien-
tific interests and spirit of the attending medical and
surgical staffs.
THE ROOM, THE TABLE, GENERAL CONVEN-
IENCES, ETC.
In the post-mortem room o£ the hospital there is
usually provided a revolving, concave table through
which fluid.s ili'nin easily iFig. 1). There is abund-
ant and unobstructed daylight; hot and cold water ai-e
ivithin ready reach; suitable sinks must be present;
B[xmges, cloths, aprons, soap, basins, disinfectants and
General Considerations. 3
plates are all in their place; in order to support the
head and neck, suitable rectangular wooden blocks
with semi-circular excavations are at hand.
Pure, unobstructed daylight is required for cor-
rect color interpretation; a post-mortem examination
completed in artificial light may not be absolutely
trustworthy in its results, particularly as regards the
parenchymatous organs, and a final resort should
always be had to the microscope.
In a private house the available room with the best
light and the least furniture should be selected in which
to hold the autopsy. The body can be placed on a
firm kitchen 4able or left lying on the undertaker's
stretcher; the floor around the body must be protected
by means of oil-cloth or old quilts. Abundant pro-
vision for cleanliness in the shape of wash-basins
with warm and cold water must be made; towels
and sponges should be handy. Bloody hands stain all
objects handled, and a corpse with its surroundings
spattered and smeared with blood and other fluids does
not tend to prepossess the laity in favor of autopsies.
One basin should be set aside for washing the hands
and instruments in only, which should be done fre-
quently. Blood and inflammatory exudate dried on
the fingers is not only unpleasant, but dulls the sensi-
tiveness of the skin. As often as a drop of blood or
other fluid falls upon the body it should be sponged off
and one should not wipe his knives on the skin of the
cadaver. In the hospital post-mortem room water
can be allowed to run over the body at frequent in-
tervals, provided care is exercised that its liberal use
4 The Technique of Post-Mortem Examination.
does not in any way obscure the condition of the
cavities and their contents. Water, when poured freely
over a recent, clean, cut surface does not permit one to
form any idea as to the original dryness or moisture of
the tissue; on the other hand blood and other fluids
are nicely removed by dipping the organ in a basin of
clean water or directing a small stream over the sur-
face. The knives should be scrupulously clean when
the organs are incised and all knives and scissors
should be sharp. Smooth and instructive cut surfaces
cannot be made with a dull and nicked knife blade;
vessels and canals cannot be incised readily and neatly
with a dull pair of scissors.
On beginning a post-mortem examination the in-
struments required should be placed in order upon a tray
or board and each instrument, when not in use, should
be rinsed in water and returned to its proper place.
THE TIME AFTER DEATH FOR THE AUTOPSY.
At the present time the positive unqualified
statement that the sooner after death the autopsy
the better, can safely be made. Decomposition, even
though slight, makesL the finer histologic and much
bacteriologic examination useless. Nuclear figures
disappear almost immediately after death as the body
cools, and this is also true of the vascular endothelium ;
the delicate lining of mucous membranes desquamates
and as time passes secondary post-mortem microbic
invasion of the tissues and of the blood may have
taken place to such an extent as to seriously interfere
General Considerations. 5
with the establishment of reliable results from the
bacteriologic examination, and as decomposition ad-
vances, even the gross changes are greatly altered and
become correspondingly difficult of detection and cor-
rect interprefatiwi. When rigor mortis is fully de-
veloped the distribution of the blood throughout the
body at the time of death. becomes somewhat changed,
and observations in regard to the condition of the differ-
ent portions of the vascular system with reference
to the amount of blood contained in them diminish
in value. The practice observed in many public
hospitals and institutions of delaying, for various in-
adequate reasons, the autopsy a certain number of
hours after death, in some instances as long as two days
or more, is consequently often directly destructive of
valuable pathologic material, and it should be abol-
ished for the valid reasons above indicated. On the
other hand it is almost unnecessary to state that no
degree of decomposition should be allowed to deter
from the exhaustive thoroughness of the medico -legal
examination.
EMBALMED AND FROZEN BODIES.
Should the body have been embalmed before the
autopsy, then great care must be exercised in the inter-
pretation of the appearances observed in the tissues,
because the fluid usually employed is capable of greatly
changing the consistence and the color of the structures
with which it comes in contact. If the fluid has been
injected into the arterial system through any of the
large arteries at one of the most superficial points in
6 The Technique of Post-Mortem Examination.
their course, then the changes in the blood vessels and
in the heart are very extensive and preclude the recog-
nition, with the naked eye at any rate, of the nicer
changes that might be present. The lungs are usually
also greatly altered, the parenchyma presenting a rough
shrivelled appearance, as though extensive coagulation
had occurred ; usually a certain part of the total blood
mass is removed at the same time as the injection is made,
so that after such time it is not possible to form any
correct idea as to the blood distribution throughout the
organs. Frequently only ''cavity embalming" has
been done; in this case a long coarse trocar has been
passed into the abdomen and attempts made to puncture
the intestines in as many places as possible, and then
penetrations are made in the direction of the heart,
large blood vessels and lungs; subsequently large quan-
tities of strong fluid are pumped into the abdomen
through the canula.
In addition to the actual change in the appearance
of the tissues that come in contact with the embalming
fluid, the numerous punctures may do serious damage
in opening abcess and other cavities and allowing
fluid accumulations and collections of various kinds to
become distributed throughout the large sacs. Occa-
sionally a certain quantity of embalming fluid is forced
into the mouth, and small portions may find their way
down into the lungs and produce very anomalous and
perplexing appearances, and it might not be altogether
impossible for some of the fluid to gravitate into the
stomach to the annoyance and mystification of the toxi-
cologist. The embalming fluid most frequently em-
General Considerations. 7
ployed contains among other things arsenic and porro-
sive sublimate in large quantities, and the proclivity of
undertakers to promiscuous embalming is notorious.
The almost universal absence in nearly all the States of
specific and strict statutory instructions bearing upon
this dangerous, useless and at present unrestrained
practice is certainly a matter of serious concern that
ought to receive immediate and prompt attention on
the part of the authorities.
If the body to be examined be frozen, arrange-
ments must be made for thawing it out thoroughly
before any examination for any purpose whatsoever is
attempted, for the obvious reasons that many organs,
as for instance the brain, cannot be removed if frozen
without fatal damage, and also because the consistence
of various tissues and the absence or presence of throm-
bosis as well as many other important details cannot be
(determined in structures partly or completely frozen.
The German regulations for the guidance of medi-
cal jurists in conducting post-mortem examinations for
legal purposes, paragraph 7, say : '^Frozen bodies, — If the
body is frozen, it is to be brought into a warm room,
and the examination is not to be proceeded with until
the parts are sufficiently thawed. The employment of
warm water, or other warm substances for expediting
the thawing is not allowable."
THE KECORD.
It is one of the most essential features of a trust-
worthy post-mortem examination to carefully and
accurately record the observations at the time they
8 The Technique of Post-Mortem Examination.
are made. It is by cultivating the habit of exact
degcription of thoroughly studied appearances that
results of permanent value are reached. The post-
mortem records of hospitals and other institutions consti-
tute, when properly kept, available sources of scientific
information of importance and value. Consequently
an assistant or two are always necessary, if for no other
purpose, in order that full and reliable notes may be
takeii during the progress of the examination. The
presence of critical observers stimulates to care and
deliberation ; medical men should always be invited to
be present It is a good law which requires that two
physicians must jointly make the medico-legal section ;
in Illinois and many other states the individual physi-
cian is singly entrusted with the most difficult case. In
important medico-legal cases it will be found very ad-
vantageous to have a full steaographic record made on
the spot; such a report embodying an accurate and coni-
plete description of all the organs and structures in the
body greatly enhances the value of the autopsy. The
record should be made in the same order as the examin-
ation; for this reason, each part or step in the autopsy
should be completed, if possible, before the next is
commenced. If the examination be made according to
some generally established routine, then the record will
assume order and method. In the report should be
described as accurately as possible what is actually
observed; the description should be concise, clear, un-
embellished; it must not include deductions or opin-
ions, the appearances are not to be interpreted at the
same time as they are described; they are to be de-
Gei^eral Considerations. 9
scribed in all necessary detail, not labelled except under
the head of diagnosis. The proper post-mortem record
should describe the morbid changes and states so
clearly and so thoroughly that a correct interpretation
or diagnosis can readily be made by any competent
man after reading the worded description. The record
should embody the following subdivisions:
I. Preliminary data, including name, sex, age,
color, time of death, time of examination, place of
examination, and, in medico-legal cases, the names of
the persons present and especially the names of those
by whom the body is identified. The temperature of
the weather and of the room should be noted where the
question of decomposition is to be considered. In
medico-legal cases the matter of proper identification of
the body must be carefully attended to. The body
should be positively identified in the presence of the
examiner by some one who knew the dead individual
during life, and the names should be written down then
and there. If positive identification cannot be obtained,
then a full, detailed description of the personal char-
acteristics of the dead body must be taken, and, if possi-
ble, the face should be photographed and attached to
the record.
II. Summary of the Clinical History. This
should always be incorporated in the routine record of
the autopsy. Clinical information should be gathered
from the medical attendant, the friends, the police, or the
hospital records, as the case may be, and noted down,
so that the post-mortem examination may be made as
intelligently as this knowledge can make it practicable.
10 The Technique of Post-Mortem Examination.
In hospitals the ward history or a summary thereof
must accompany the patient to the dead-house.
III. The exferior of the body. Here is included
a note as to the size, the development, the nutrition,
the rigor mortis, post-mortem lividity, evidences of de-
composition and an accurate description of the external
lesions or abnormalities of various kinds that may be
found. In medico-legal examinations the accuracy of
the external description is of great importance. All
marks of violence must be carefully described with
great minuteness of detail as to location, with reference
to fixed anatomic landmarks; as to size and shape,
which must be described with mathematic precision;
as to the color, the condition of wound margins and the
surrounding skin. The condition of the various orifices
must also be noted in connection with the inspection
of the body. If the body is that of an unknown per-
son observations in regard to the following facts are to
be recorded for the purpose of possible future identi-
fication, to- wit: color, age, sex, height, weight, build,
forehead, face, eyes, nose, hair, teeth, beard, mustache,
complexion, scars, marks, condition of fingers and toes,
overcoat, coat, vest, pantaloons, underwear, shawl,
cloak, dress, boots, shoes, stockings, necktie, shirt, hat,
cap, personal property, probable occupation and reason
why, etc., as well as a note of the locality where found.
IV. Internal Examination, The record should
contain a detailed account of the condition and the
appearance of the organs, the tissues, and the cavities of
the body. It embodies a systematic chronicle of the ob-
General Considerations. 11
servations, as regards the following in connection with
the solid organs: The weight, the size as determined
by actual measurement, the consistence, the condition
of the external surface and the edges as regards unusual
roughness and irregularity or change of contour; the
degree of union between the capsule or covering mem-
brane and the surface of the organ ; the cut surface —
its color, smoothness, the amount of blood, the amount
and character of other fluid, the condition of the surface
markings as observed in the liver and the kidney, the
vessels, the odor, the character of the surface scrapings,
and lastly the results of the chemical or microscopic
examination, or if these be not undertaken at once, the
disposition of the tissues for this purpose should be
noted down. In regard to the cavities of the body
notes are to be made as regards the contents, — the
quantity, the color, the consistence, the odor, the reac-
tion, the sediment; then the lining membranes must
be described with reference to color, smoothness, lustre,
abnormal adhesions, deposits and so forth. The hol-
low viscera are described as regards contents, the con-
dition of the surfaces, the size and such other points as
may be prominent in the individual case. Should the
contents of the digestive tract require chemical exami-
nation, then a full note is to be made in regard to their
preliminary treatment for this purpose. The descrip-
tion of the colors should be exact, specifying in each
instance the particular variety observed. The size
of the organs, or of abnormal areas or growths
should be determined by means of actual measurement ;
to say that an object is as large as a pigeon's egg, a
12 The Technique of Post-Mortem Examination.
millet seed or a walnut, is not as exact as to give the pre-
cise dimensions. In these general suggestions pointed
directions as to the method of describing extensive or
marked morbid changes or growths cannot well be
formulated; in a general way it may be said that the
various points to be considered in the description of the
solid organs apply here also.
V. The Diagnosis, Under this subdivision of
the record are to be enumerated in the most natural
order the various anatomic changes observed and de-
scribed during the autopsy. Usually the order of im-
portance as regards the cause of death is selected. The
anatomic diagnosis represents the opinion of the path-
ologist with reference to the nature of the lesions
observed and this is the only part of the record where,
as a general rule, opinions ought to be written down.
Only the morbid changes are to be summarized in the
diagnosis.
Such a record as here indicated should be made at
every post-mortem examination. In many hospitals
printed outline forms are furnished upon which the
reports are written down. Such forms are useful as a
general guide to the beginner and the non-expert phy-
sician, by referring to which omissions are less likely
to occur. The principal objection to such forms, which
undoubtedly are time saving, lies in the fact that they
cannot be so arranged as to allow sufficient individuality
of description in the proper places of the special find-
ings. With reference to that particular variety of
medico-legal cases known as coroner's cases, it may be
said that in this country the cause of death is determ-
Generax Considerations 13
ined by a jury of laymen; consequently the kind of
statement wanted from the physician who makes the
autopsy is one that clearly and concisely describes the
nature and the cause of death. The statement to the
coroner's jury should be worded so that a fairly intelli-
gent layman can readily grasp its meaning and it
should not include the many and otherwise important
details which must be found in the complete post-mor-
tem report. The examination in such cases must be
exhaustively thorough and a full, detailed record
should be made during its progress for future refer-
ence, as, for instance, during the criminal trial; but
the statement to the coroner's jury need only be a
comprehensive, clear summary of the findings sufficient
to show that the conclusion as to the cause of death
is fully warranted.
SAMPLE OF EEPORT OF POST-MORTEM
EXAMINATION TO THE CORONER.^
At an inquest upon the body of John Smith, held
July 2nd, 1893, at the Cook County Morgue, City of
Chicago, County of Cook, State of Illinois, personally
appeared ******* who being sworn according
to law, deposes and says: My name is ***** * ;
I reside at*******, and am by occupation a
physician and surgeon.
I made a post-mortem examination at the Cook
Oounty Morgue, July 2nd, 1893, upon the body of a
man who was identified in my presence as John SniHh,
^ Made on blank furnished for that purpose.
14 The Technique of Post-Mortem Examination.
of 200 Fay street, Chicago, by his neighbors, Thomas
Broun and Henry Wilson,
Inspection. The body was that of a well nour-
ished, muscular man, about 30 years of age; it was 5
feet and 11 inches long, and the estimated weight was
185 pounds. The post-mortem rigidity was strong and
there were no signs of decomposition.
The following marks of external violence were
observed: In the space between the 2nd and 3rd ribs,
just to the left of the breast bone was a wound, one
inch in length, with smooth, sharp margins, running
parallel with the ribs. There was a similar wound over
the centre of the upper part of the breast bone. The
direction of this wound was oblique from above down
to the right, and it was only one-half an inch long.
Some blood had flowed down from both these wounds
and dried upon the skin, but more from the lower than
from the upper.
Iniernal Examination, The wound between the
2nd and 3rd ribs to the left of the breast bone passed
through the pericardium or sac about the heart, and
penetrated through the wall of the heart itself; the sac
about the heart was consequently filled with fluid and
clotted blood which compressed the heart. The wound
in the heart was one-half inch long, showing the instru-
ment to have been somewhat pointed; the margins were
smooth cut.
The wound over the upper part of the breast bone
only extended through the skin, and did not touch the
bone. The brain, the lungs, the liver and kidneys, as
well as the other organs, were quite healthy. The
General Considerations. 15
stomach contained a quantity of but slightly digested
food, in which potatoes in the shape of solid pieces,
tomatoes, meat and corn could be recognized.
Conclusion, John Smith died from haemorrhage
following a stab wound of the heart.
Signed.
EAKLY STEPS IN THE PEEPAEATION OF POST-
MORTEM MATERIAL FOR MICROSCOPIC
AND BACTERIOLOGIC PURPOSES.
It is not proposed to discuss in detail all the
various modern micro-technical methods, but to merely
mention such preliminary and general procedures as
are not too complicated to be employed at any ordinary
post-mortem examination.
In order to emphasize the absolute necessity of
resorting to microscopic examination during autopsies,
it will be amply sufficient to state that Virchow enumer-
ates the following changes as capable of diagnosis only
with the aid of the microscope, and certainly the para-
mount importance of recognizing these alterations can
not be disputed:
1. The diffuse fat metamorphosis of the cells in
the interstitial tissue of the brain, the spinal cord, the
retina and the nerves.
2. The parenchymatous fatty changes in the
muscles, the heart, the kidneys, the liver, and the
peptic cells of the stomach.
3. Fragmentation of the fibres of the myocardium.
4. Gangliform swelling of nerve fibres.
5. Calcification of the ganglion cells.
16 The Technique of Post-Mortem Examination.
6. Pat embolism in the lungs and the kidneys.
7. The white hepatization and the red induration
of the lungs.
8. Initial proliferation on part of tissue elements
in general.
9. Slightly advanced amyloid degeneration.
The microscopic study of fresh tissues simply
requires that small fragments be nicely teased apart in
a one-half per cent, salt solution, mounted and inspected
in the same; semifluid substances are also best exam-
ined microscopically in this solution. For the purpose
of staining the nuclei in fresh tissues prepared in this
way, Carnoy's solution^ is very valuable; the speci-
mens can be teased or immersed in this mixture for
two or three minutes, then the color is washed away,
and the specimens mounted in the salt- solution; very
instructive mounts from the myocardium, for instance,
may be made in this way. Thin sections of fresh tis-
sue are readily made with the aid of some one of the
various forms of the freezing microtome or with Val-
entine's double knife; for further directions as to the
use of the freezing microtome see the standard text-
books on microscopic technique.
The mahogany brown color reaction of amyloid
degeneration with Lugol's solution (iodine 4.0, potas-
sium iodide 6.0, distilled water 100.0) is obtained by
dropping the solution on the cut surface of the suspected
organ and allowing it to remain for thirty seconds
' Satnrated aqneons solntion of methyl green to which is added
one per cent, of acetic acid and one-tenth per cent, of osmic acid
(Delafield and Prudden).
General Considerations. 17
or so ; in order to insure an acid reaction in the tissue
it is safest, under all circumstances, to first drop a little
acetic acid on the cut surface. The iodine solution is
washed off with water before looking for areas showing
the reaction. By applying the solution to small, thin
pieces of tissue in a watch glass or on a slide, and sub-
sequently washing in water, the reaction can be brought
out more strikingly, the tissue in general being straw
yellow, the amyloid areas brownish-red, in color.
The general practitioner as well as the pathologist
should go to every examination fully prepared to place
such pieces as may be selected from the various organs
into suitable hardening and fixing solutions immedi-
ately after their removal from the body. The sooner
after death the tissues are fixed the better can the
details be studied. To carry pieces from the organs
about in paper is uncleanly and liable to damage the
tissues. There should, consequently, be a number of
small, wide-mouthed bottles at hand, containing the
various fluids about to be mentioned, securely corked
and with proper labels affixed. As soon as the pieces
are dropped in the fluid — not more than two should be
placed in each bottle and these should be readily dis-
tinguishable tissues, such as lung and kidney, for
instance — the label should be filled out. The pieces
should be small ; as a general rule not over half a centi-
meter square; in the case of organs provided with a
<;apsule or membrane the pieces from the surface
should include the undisturbed external ooven
should be cut with a sharp knife and hao'
without compression; the pieces »^
ji
18
The Techsiqce of Post -Mortem Examination.
once into the solutioD selected and they should not be
first washed in water. Portions of mucous membranes
selected for microscopic purposes should be treated
with the greatest delicacy of touch in order not to
destroy any more of the surface epithelium than can be
avoided. In the case of membranous organs small
pieces may be pinned with the mucosa or internal
membrane upward on flat, thin slices of cork and then
placed singly in a bottle of the hardening and fixing
solution. The label should show the history of each
piece in the bottles: The name or number of the body
examined, the date of the autopsy, the length of time
after death, the organ and the district in this from which
the piece is taken and any other information necessary
(Fig. 2).
Flgt. C— BoIIU
1. Alcohol. Absolute alcohol fixes and hardens
many tissues quite satisfactorily. Tissues that are to
be examined for bacteria are usually placed in absolute
alcohol. There are a number of tissues, however, in
General Considebations. 19
which alcohol produces such changes as contraindicate
its use. Alcohol dissolves the fatty substances, espec-
ially in the nervous as well as many other tissues, which
on this account are not placed in this fluid. Alcohol
also dissolves the red blood corpuscles and when cir-
culatory processes are to be studied the tissue should
be fixed in fluids that preserve the blood cells.
The ease with which alcohol is obtained and its
almost universal adaptability as a hardening agent when
only the more general and topographic features are
considered need not, however, even in the country,
force the physician to rely solely upon spirit.
2. Muller's fluid.'
Potassium bichromate 2^ parts.
Sodium sulphate 1 part.
Distilled water. By weight 100 parts.
This is a cheap, easily and universally obtainable,
valuable solution ; it is used most extensively for the
nervous system, but it can be and is employed witli
equal advantage foral most every soft tissue in the body.
There are numerous modifications of this solution, but
for general purposes the formula given will answer
very well. This solution fixes and preserves the sub-
stances extracted and dissolved by alcohol, namely tlie
blood corpuscles and the fat. The pieces should ])o
small and the quantity of fluid quite largo and fit firHt
the solution must be changed often, every day. M fil-
ler's fluid will harden quite large pieces, even wlioln
organs, such as the brain and spinal cord, when cfiro is
^ Of late a 2 to 2*5% aqneooB Aolution of bichrornaio of poifiN
Binm has replaced MOller^s fluid to quite an eiteiit; eiihi^r oiio tnuy
be used.
20 The Technique of Post-Mobtem Examination.
used to change the fluid often. For the further treat-
ment of tissues placed in MtlUer's fluid reference is
made to the text-books on microscopic t-echnique. At
the present time it is suflScient to insist upon the
placing of small pieces of tissue and even whole organs
in this fluid immediately upon their removal from the
body and without washing in water, the fluid to be
changed daily.
8. Fle)in)tiiig''s solid ion,
A. 1% aqueous solution chromic acid. .11 parts.
Glacial acetic acid 1 part.
Distilled water 4 parts.
B. 2% solution of osmic acid in 1% aqueous chromic
acid solution.'
For use, mix 4 parts of A and 1 part of B. By
mixing the two solutions when necessary there is no
danger of deterioration and in this way the cost of
Flemming's solution is much diminished.
^ " The osmic acid may be obtained from the chemical houses,
and comes in sealed glass tubes containing either l^ or 1 gram of
the crystals. In making the solution B, the following precautions
are to be observed: The glass-stoppered bottle in which the miitnre
is to be kept is thoroughly washed with water, then rinsed with
sulphuric acid, and finally rinsed with distilled water. The requisite
qu "Entity of one per cent, chromic acid is now made in the cleaned
bottle, using distilled water and pure chromic acid for this purpose.
If we had one gram of osmic acid we would require 60 c.c. of the
chromic solution. The tube containing the osmic crystals is now to
be freed of the label, thoroughly washed in water, scratched with a
file, and dropped into the bottle of chromic acid solution. By means
of a clean glass rod the tube is now broken, the bottle stoppered and
set aside."— (Ohlmacher, North American Practitioner^ February,
1892.)
General Consideb axioms. 21
When the tissues are obtained absolutely fresh,
i.e , immediately after death, they should be subjected
to real and precise fixation with Flemming's solution in
order that the finer, ultimate details of the cellular
structure can be studied. The pieces should not be
any larger than 4mm. square and enough solution
should be poured on to cover the specimens. After
twenty-four hours they are washed with running water
for two hours or immersed in frequently changed, quiet
water for six hours; then dehydration in alcohol of
gradually increasing strength is commenced: 50% alco-
hol 2 to 6 hours, 70% 6 to 12 hours, then 95% alcohol
for 24 hours, or indefinitely.
4. Saturated Aqueous Solution of corrosive snh-
limate, 1 : 14. Small pieces may be fixed in this for
one-half to two hours, washed in running water for
twelve hours, and gradually hardened and dehydrated in
alcohols of increasing strength, and preserved in 95
per cent. This solution can be extemporaneously pre-
pared with the surgeon's bichloride tablets and it fixes
quite well but not as perfectly as the chromo-osmo-
acetic acid mixture.
Summary. In order to obtain valuable tissues for
the various microscopic purposes post-mortem material
should be judiciously fixed and hardened according to
the nature of the tissue and the case.
Every effort should be made to obtain the tissue
as fresh as possible.
Alcohol, Mtiller's fluid, Flemming's solution or a
saturated aqueous bichloride solution should be at hand
in suitable bottles.
22 The Technique of Post-Mobtem Examination.
Perfectly fresh tissues should be fixed as directed
in Flemming's mixture, or in its absence in the bichlo-
ride solution; such tissues can subsequently be stained
for bacteria and karyokinesis.
Absolute alcohol is to be used when the tissues are
removed some time after death, and are to be examined
bacteriologically.
Mailer's fluid is always to be used for hardening
the brain and the spinal cord ; almost any tissue can be
hardened in this fluid and subsequently studied with
very good advantage as regards the ordinary patho-
histologic changes.
Tissues fixed in Flemming's or in the bichloride
solution can be transported to laboratories while still in
the fixing solution, if the distance allow it; otherwise
they can be sent after they have reached the 95 per
cent, alcohol. Tissues in alcohol or in Mftller's fluid
can be sent as they are.
Structures lined or covered with epithelium, such
as the ovaries, the uterus, the intestines, the ependyma
of the encephalic cavities etc., should be handled as
little as in any way possible so that the delicate cells
are not needlessly rubbed off.
Opportunities to make cultures and smear prepar-
ations during a post-mortem examination should not be
neglected even though the more elaborate appliances
for carrying on bacteriologic investigation are not
within immediate reach. Smear preparations can be
made from abscess contents, fluid accumulations, exu-
dates as in pericarditis or pleuritis, the blood, endocar-
dial vegetations, the cut surface of solid organs, etc. ; a
General Consideration. 28
minute quantity of blood or of fluid is placed upon the
thin glass cover, or the cover-glass is brought in direct
contact with the freshly cut surface of such organs as
the liver or lung, or a little moisture or solid material
is carried from the cut surface to the cover-glass with
an aseptic metal spade or a forceps. The material thus
brought upon the glass should be distributed over the
surface as evenly and as thinly as possible ; two glasses
may be pressed together and then separated by sliding
them apart; this will usually leave a thin layer on the
surface of each slip, or the material may be spread out
evenly and thinly by drawing the end of a smooth-edged
glass slide over the face of the cover slip near the edge
of which has been placed a small drop. StemVjerg
prefers to spread the material on a slide instead of on
a slip, because the latter is easily broken or lost during
the subsequent manipulations. The even, thin layer
upon the surface of the absolutely clean and dry cover-
slip or slide is now allowed to dry in the air, and then
the preparations are passed three times through the
flame of an alcohol lamp, the smeared surface u[>ward,
in order to coagulate the albumen and make the inat^;-
rial adhere to the glass. If the glass slide is used this
can be held with the fingers; the c/fver Hli[> smears, on
the other hand, are held in small f()rcAt[m. \Vh<^n from
blood it may V>e liest U) fix the smear [;re[mration in
equal parts of HlmiAnUf nUutUifl and ether
Daring the foregoing manipulations all [/recautionw
against accidental ^j^/n tarn i nation muHt \h* rigidly
obser\'erl; the cHviiUtH or tinwuen moirt *•* ' '.ttu*d with
sterilized knivc*s. and the tnHUtrisil hto ^i
24 The Technique of Post- Mortem Examination.
the glass which has been cleansed in alcohol and
thoroughly dried; all knives, forceps and spades used
for this purpose are readily sterilized in an alcohol
lamp flame.
Smear preparations of this kind will keep for a
long time and may be forwarded to the laboratories by
placing the slides in the common slide boxes while
unmounted cover-glasses may be gummed to cardboard
on the side opposite to the film ; the cardboard can now
be packed in tin or wooden boxes so that the covers are
free from contact.
The value of the results obtained by staining and
studying smears is, of course, not as great as desirable
except in the case of such microbes as have a differ-
ential stain, like the bacillus of tuberculosis. In the
majority of instances culture media must be inoculated
and the characteristics of the microbes in the growing
colonies observed before definite bacteriologic diagnosis
can be established.
Test tubes with the usual solid culture media can
be brought to the post-mortem examination and inocu^
lated during its progress, when the distance from the
laboratory is not too great. Stab cultures of this kind
are made with a sterilized platinum needle which trans-
fers minute bits of tissue or fractional drops of fluid
into the medium in the tube through the centre of
which they are plunged; the tube is usually held
inverted with the left hand, the cotton plug is removed
and held by its very top between the fingers of the
same hand, while the needle is carefully introduced
through the centre of the tube without touching its
General Considebations. 25
sides; if the upper surface of the medium is slanting,
then a scratch may be made along the oblique aspect.
Immediately after the stab or the scratch the plug is
reintroduced and the surface outside the tube singed
in the flame.
Organs and cavities from which material is planted
in this way are incised with newly sterilized knives or
scissors, and in addition the cut surface is again steril-
ized before the needle is forced into the tissue below-
Tubes inoculated in this manner can be transported
for some distance provided the temperature is not such
as to stop the growth of certain sensitive bacteria like
the Micrococcus lanceolatus. For the purpose of trans-
portation the following precautions must be observed:
Cultures on 8-10 per cent, gelatine should have the
upper ends of the tubes closed by fusing the glass, as
they may melt and run into the plugs. Upon arrival
the end may be cut off and a cotton plug inserted in
the tube.
Agar agar and 15 per cent, gelatine may be sent
without danger of melting. However, as there is often
some expressed fluid in tubes a double cotton plug is
sometimes advisable; this is a small sterilized cotton
plug below the one in the end of the tube and is
inserted to catch any fluid present.
Tubes should be packed in strong wooden boxes
with enough cotton to absorb all the fluid present in
case of breakage. Tubes in quantity should be sent by
express as they receive more care. The top of the box
should be plainly marked " This side up^
26 The Technique of Post-Mobtem Examination.
In case it should l>e concluded to send fluid or
soli<l material, then sterilized tul>es and glass stoppered
])ottles must be provided ; such tubes and bottles should
]>e carried in a strong sterilized paper box, hermetically
sealed with oil paper, and not opened until everything
is ready for use. The tissues and fluids are conveyed
to the tubes by means of sterile spades and other instru-
ments, and immediately thereafter the upper ends are
closed by fusing the glass. The wide-mouthed, glass-
stoppered bottles should be covered with tin foil in
order to keep out the dust.
When specimens are to be kept cold the tubes or
}>ottles may be wrapped in cotton and cloth and placed
in a larger jar filled with a strong salt brine and ice.
All bottles and tubes should be packed in sufficient
cotton to absorb all the fluid present. Smaller speci-
mens may be sent by mail,^ but should then be in strong
metal cases or in the official mailing cases.
POST-MORTEM DISSECTION WOUNDS.'
The ordinary forms of wound infection, simple
suppuration, cellulitis, lymphangitis, regional lymphad-
enitis, erysipeloid, erysipelas, etc., are not what we most
dread in making post-mortem examinations. It is the
development of sudden violent septicemia which is most
appalling, although the first mentioned forms are by no
means trivial.
Individual failure of immunity plays a powerful
part in the causation of these diseases. But, as Welch
iL.
'By a recent decision from the Post Office Department material
of this kind that is considered infections is excluded from the mails.
^Prepared at anthor*s request by Dr. Weller Van Hook, Chicago.
Genebal Cohbi derations. '27
has justly said, in those severer forms of infection which
destroy in a few hoars the lives of healthy men who
have inoculated themselves through trivial wounds, it
is the quality of the infectious material which brings
about the fatal result, and not any especial predisposi-
tion on the part of the individual.
The ideal treatment of post-mortem wounds would
be the immediate disinfection of the injured tissues in
all cases with the same care ae would be given if it
were absolutely certain that such a virulent poison were
always present. This treatment might be formulated
as follows:
(1.) Instantaneous interruption of venous and
lymphatic circulation by any convenient constricting
band.
(2.) Careful disinfection of the skin about th^
injured part by scrubbing with a strong antiseptic solu-
tion (one per mille corrosive sublimate or five per cent.
carbolic acid).
(3. ) Exposure of all parts of the wound, if neces-
sary by incision with a sterilized instrument. The
escape of blood and lymph should be encouraged.
(4) Application of a strong antiseptic solution
(ninety-five per cent, solution carbolic acid) to all parts
of the wound.
id ap[iliL'a-
lent
prefer
28 The Technique of Post- Mortem Examination.
to " take their chances " without resorting to this elab-
orate treatment, the following rules may be suggested
as being less radical:
(1.) Never begin a post-mortem examination
until all cuts upon the exposed skin have been either
cauterized to destroy the absorptive power or securely
covered with impermeable material (such as rubber
gloves, finger cots, or antiseptic cotton fastened down
by a solution of caoutchouc in chloroform*).
(2.) In the event of a wound occuring during
the examination, grasp the injured member above the
point of injury and, if possible, force a few drops of
blood out of the wound.
(3.) Scrub the region of injury with a good anti-
septic solution.
(4.) Clip away the epidermis, if necessary to
expose the wound.
(5.) Cauterize the wound (if an ordinary punc-
ture or small incision) with ninety -five per cent, car-
bolic acid worked well into the bottom of the wound.
(6.) During the remainder of the autopsy wear
an impervious dressing over the wound, unless some
one can step in and finish the work.
(7. ) After the examination apply upon the wound
a wet antiseptic dressing.
(8.) Never seal up a dissecting wound with col-
lodion or caoutchouc solution.
(9.) After receiving such a wound be on your
guard for evidence of infection, in order to treat it
promptly.
[^Collodion does not farnish a waterproof dressinj^f.]
General Considebations. 29
STATISTICAL.
The following statistical material (principally from
Vierodt's Daten unci TabelleUj Jena, 1893) is intro-
duced for the sake of convenience of reference:
Average Weight and Dimensiona of Healthy Adult Organs.
WEIGHT. DIMENSIONS.
Adrenals 4.8— 7.29 .. . .45x2.8x0.5 cm.
Brain * i oo-t ^ 15 — 17 — 14 X 12.5 cm.
w. 1160 g
„ . m. 300 g
^^^^ ; -w. 250 I ; ^
Length 8.9 cm., width 8.5 — 10 cm., thickness 3 — 3.0 cm.
Circumference at base of ventricles ..... 25.8 cm.
Thickness of left ventricular wall. 1 — 1.4 cm.
Thickness of right ventricular wall 0.3 — 0.5 cm.
Depth of left ventricle 9.5 cm.
Depth of right ventricle 10.0 cm.
Circumference of mitral orifice 10.4 — 10.9 cm.
Circumference of tricuspid orifice 12. — 12.7 cm.
Circumference of aortic orifice 7.7 — 8.0 cm.
Circumference of pulmonary orifice 8.9 — 9.2 cm.
Kidneys, (conjoint w'ght) 299 g . 11—12 X 5—6 X 3—4.5 cm.
Cortex thickn's 0.4 — 0.6 cm.
Eelation of cortex to medulla ..1:3
T r. 513 QT
Luns^s ^ ii-i
^ 1. 441 gr
Liver 1610 g. . . .
Length from right to left 25 — 32 cm.
Width of right lobe 18—20 cm.
Width of left lobe 8—10 cm.
Vertical diameter right lobe 20 — 22 cm.
Vertical diameter left lobe 15 — 16 cm.
Greatest thickness 6 — 9.5 cm.
Ovaries 7.0 g 4.5x2.7x1.3 cm.
Pancreas .... 66—102 g 19. X 2.2 X 4.0 cm.
Prostate 20.0 g 4.5x2.7x2.0 cm.
Spleen 171 g 12.0x7.5x3.0 cm.
30 The Technique of Post-Mortem Examination.
o • 1 J oo oo 4-4-.8 cm. loQfif in m.
bpmal cord . . oo — oo g i-t a i^« •
^ ^ 41.0 cm long in w.
Stomach .... 170 -232 g
Testicles .... 15 — 24.5 g
Thyroid 30—60 g X 3.r) X 2.0 cm.
Uterus (after births) 110 g 9x6 X3.5 cm.
SPECIAL INSTRUMENTS AND APPLIANCES.
In this brief enumeration no attempt has been
made to describe the complete outfit of the modern
pathologic laboratory. The fully equipped pathologic
institute or hospital dead-house will contain elabo-
rate apparatus for special purposes which has been
intentionally left out of consideration.
Many an examination must, of course, be made
with few of the instruments and conveniences referred
to ; au autopsy can be thoroughly performed with a few
knives, scissors, forceps and a saw. At the present
time, however, the satisfactory and complete examina-
tion of a dead body requires the almost constant use of
the microscope and its accessories; the tissues and
fluids will frequently demand bacteriologic investiga-
tion ; obscure medico-legal cases exact the aid of the
microscopist, the bacteriologist as well as the chemist,
and while the post-mortem examination in the majority
of such instances is really only the first step in the
investigation, yet everything depends upon the fact
that the work must be complete and correct from the
very beginning. Every fair-sized town or city should
consequently provide a suitable place with all the
necessary appliances in order to insure the complete-
ness of examination which all medico-legal cases de-
mand and all other cases merit.
General Considerations. 31
A complete set of post-mortem instruments includes :
Knives, — For the long incisions and the coarse
dissection the section knife of Virchow is employed.
This knife is provided with a stout, deeply-bellied blade
with a well-rounded point and a heavy, large handle,
so that it can be firmly grasped with the whole hand.
An extra heavy instrument of this kind can be used
as a cartilage knife (Fig. 3). Ordinary dissecting
scalpels are necessary for the more painstaking and
delicate dissection required from time to time. The
brain knife is a long, thin, frequently doubled- edged,
sharp instrument used for incising the solid organs
so that they may present smooth and extensive cut
surfaces upon which the structural condition can be
studied (Fig. 4). A curved probe-pointed bistoury
is handy for cutting through the dura in removing the
brain. A razor or a Valentine's double knife is some-
times employed for making thin sections of the fresh
tissues.
Scissors. — Probe-pointed scissors are employed
for incising vessels and canals of various kinds. Fair
sized ordinary scissors with one blunt and one sharp
blade are also necessary. The enterotome, useful for
opening the intestines and also the heart, is a large
pair of scissors, one of the blades of which is provided
with a blunt, projecting exiffemity; this projection
should be smooth, and free from any sharp points or
edges that may catch in the folds of the intestinal
mucosa or in the columnse carnese of the heart (Figs.
5 and 6).
Fin;. 3.— Stout Knife.
i-i'
08
rs
.a
o
I
6t
Flip. 6.— Improperly
constructed Enterotome with
sharp hook.
Flff. 5.— Properly made
Enterotome with smooth blunt
projecting point.
32
General Considerations. 33
Dissecting Forceps. — Two or three pairs of dif-
ferent sizes.
Probes. — Large and small; also, grooved director.
Saws. — A butcher's saw will answer quite well.
A bone saw with movable back and detachable blade
with fine teeth and well set is preferable. For sawing
the laminae of the spinal column a saw with a curved
handle and a rounded broad blade may be used or a
double saw, like Luer's rhachitome. In removing por-
tions from the base of the skull a key-hole saw is
desirable (Fig. 7 and 8).
Chisels. — A chisel with a straight edge and a
strong wooden handle, the blade being about 3 cm.
broad, will answer very well. A T-shaped steel chisel
is often placed in the case of instruments, and some-
times the blade has a guard placed on it, say one-third
of an inch from the point, to prevent the chisel from
injuring the brain in removing the calvaria (Fig. 9).
Brunetti's chisels for opening the spinal canal
from the front are now considered unsafe because of
their liability to produce artificial heterotopia in the
spinal cord, but they may nevertheless be found very
useful in private examinations (Fig. 10).
Mallet. — A heavy wooden or rawhide mallet
(Fig. 11) drives the chisel better than the ordinary
steel hammer, the blunt hook on the end of which is
useful in jerking off the calvaria. A cross-handled
hook is also useful for this purpose.
Bone Forceps. — Large, strong.
Lineal and Liquid Measures. — Every case of
post-mortem instruments should include a cup of fair
General Considerations. 35
^ capacity for measuring fluids (Fig. 12) ; also a brass
or wooden foot-rule graduated into inches and centi-
meters. Caliber compasses with graduated cross-bar
are of course very handy. In autopsy rooms graduated
glasses of all kinds must be at hand.
Scales. — The weights must be suitably sub-divided
In private and medico-legal work a pair of balances
able to weigh altogether, say, 2,000 grammes will be
found very useful. Weighing determines actual in-
crease or decrease on part of an organ much more
accurately than measurements. In large dead-houses
scales should be arranged for the ready weighing of
the whole cadaver; a fulcrum and lever arrangement
underneath the post-mortem table would weigh the
body as it is placed in position for the autopsy.
Graduated Cones. — These should be from a frac-
tion of to several centimeters in diameter and are used
for measuring orifices and tubular organs (Fig. 13).
Metal and Flexible Catheters.
Blow-Pipe with Stop-Cock.
Post-Mortem Needles and Barbour's Linen
Thread No. 26.
Litmus Paper.
Sponges, Pails, Vessels, and Plates.
Magnifying Lens.
Microscope and Freezing Microtome and Ad-
juncts. — A microscope with the necessary adjuncts and
a freezing-microtome, or, in lieu of this, a double-knife
make a fairly definite diagnosis possible on the spot,
General Considerations. 37
and it goes without saying that this method of testing
the macroscopic diagnosis should be employed as
frequently as it is possible.
Photographer's Camera. — This is an exceedingly
valuable accessory for the accurate reproduction of the
appearance and the location of wounds as well as of
interesting pathologic conditions and specimens which
for some reason cannot be preserved. All unknown
bodies should be photographed as a possible means
of future identification.
Tubes with Sterilized Media. — These should be
at hand ready for inoculation and the platinum-needle
and alcohol lamp must not be forgotten.
Bottles and Jars. — Suitable clean, well-stoppered
bottles and jars, provided with labels, and also some
standard preserving and fixing solutions are absolutely
necessary for the proper care of pathologic specimens
and tissues, and in cases of suspected poisoning.
Injecting Syringes and Solutions.
EXAMINATION OF THE BODY.
The body is placed upon the table in the supine
position; all clothing, including the stockings, is to
be removed; the table, if movable, is placed in the
most favorable light; whatever instruments are con-
sidered necessary are placed in order upon a suitable
tray or board; pails, basins and pitchers with warm
and cold water are at hand; in short everything is
placed in order after the manner of the well-arranged
surgical operation.
Under all circumstances the examination of the
exterior of the body is always and invariably the first
in order.
INSPECTION.
In a general way inspection determines the stature,
the sex, the color, the height, the approximate age, the
development, the degree of general nutrition, and the
other usual characteristics of the body. Whenever
possible the exact weight of the body should be estab-
lished. In order to determine the exact shade of color
in the skin the body must be thoroughly clean ; other-
wise there is great danger of not recognizing or of
confounding with each other the various forms of acci-
dental or morbid cutaneous discoloration. The state of
tlie general nourishment is well shown by the fullness
and roundness of form and by the degree of mus-
cular thickness and prominence. The thickness,
38
Examination of the Body. :iU
the tension and the elasticity of the skin are deter-
mined by raising it into folds. Inspection takes j^ar-
ticcdar notice of the signs of death, decomposition,
and external pathologic or traumatic changea The
degree of rigor mortis present is determined; it must
be remembered that cadaveric rigidity is first to show
itself about the muscles of the lower jaw, from which
it gradually extends downward; it disappears in the
same sequence. The livores mortis, or post-mortem
lividity, are of normal post-mortem occurrence; they
are reddish or livid discolorations that appear most
marked on the undermost parts of the dead body and
they are due either to simple gravitation of the blood
within the vessels or to the diffusion of the blood color-
ing matter into the perivascular tissue — sometimes so
extensively as to map out the whole cutaneous network
of veins. These gravitation and diffusion stains are to be
distinguished from the greenish discolorations that are
due to the changes of decomposition and which show
themselves first where the viscera are nearest the surface,
as in the lateral regions of the abdomen.
In medico-legal cases the nature of all areas of
discoloration upon the dead body must be definitely
settled, and the following are some of the more impor-
tant points to take into consideration: their location,
size, and shape; the effects of pressure upon removing
the color; the exact color or colors observed; the
absence or presence of elevation or tension over the
area; and finally the condition of the underlying tissue
as regards infiltration with fluid or clotted blood.
Neither of the post-mortem discolorations are accom-
40 The Techxique or Post-Mortem Examination.
panied with surface elevation; extrayasations usually
are. The post-mortem hypostasis stain can be removed
for a moment by pressure. Incisions through the skin
must always be made for positive differentiation: the
ordinary post-mortem discoloration will not show any
free blood in the tissues outside the vessels; in extrava-
sations, on the other hand, caused by contusions or
other modes of violence, the tissues will be more or less
extensively infiltrated with free fluid or clotted blood
due to the rupture of the blood-vessels. It is to be
recollected that blows upon the body within two hours
after death may cause ecchvmoses and extravasations
which cannot, under some circumstances, be distin-
guished with certainty from some of those formed dur-
ing life, and that decomposition, if somewhat advanced,
may so change appearances that a correct interpretation
may become very difficult.
The examination of the exterior of the body for
pathologic or traumatic changes must be minute and
systematic, and it should take up the various and
several parts of the body in order. Commencing with
the head, the scalp is to be examined for wounds and
scars and the condition of the hair noted. The eyelids,
the eyeballs, and the pupils are to be inspected ; if one
eye should be found to have been absent or useless for
some time, then it might be very interesting and profit-
able to secure a reliable study of the visual tracts in
the brain. The nose and the ears are to be examined
for foreign bodies, for the presence of blood and other
fluids. The color of the lips and the nose should be
noted; the condition of the teeth, the situation of the
Examination of the Body. 41
tongue, the presence of fluids or foreign boilies in the
mouth are all points of great importance in medico-
legal cases. Sometimes rigor mortis closes the mouth
so firmly that it becomes necessary to pry it open with
a chisel inserted between the teeth. The neck is to be
closely examined for livid spots and marks of violence,
glandular enlargements, etc. The fullness of the mam-
mary-glands and the absence or presence of milk
should be noted in women. The degree of abdominal
distension, the presence of lined albic(mtu(, the condi-
tion of the inguinal and crural regions with reference
to evidences of hernia are points to be investigated.
In women that are suspected to have died from the
results of abortion the external genitalia are to be care-
fully examined for ruptures and lacerations, for punc-
tures and other wounds, for foreign bodies, inflam-
matory lesions, and peculiar discharges. In cases of
assault the fluids present must be carefully examined
with the microscope for spermatozoa, and suspicious
stains upon the clothing should also be investigated in
this respect. The anus is also to be inspected for
inflammatory and other changes as well as for foreign
bodies. The glans penis and the prepuce require
careful search for syphilitic and other cicatrices. The
inspection of the surface of the back must not be
neglected. Finally the extremities are taken up and
examined for edema, ulcers, scars, deformities, gouty
deposits, evidences of external injuries, such as frac-
tures, etc.
In ulcerative endocarditis, purpura hemorrhagica,
and some of the acute exanthematous diseases the skin
42 The Technique of Post-Mortem Examination.
and subcutaneous cellular tissue may show important
and interesting lesions and blood extravasations which
would merit careful histologic and bacteriologic study.
In medico-legal cases particular attention is
directed to the following special points: All wounds
must be accurately described and located with reference
to fixed anatomic landmarks; thus, for instance, the
course pursued by missiles in passing through the
body must be as definitely established as possible, be-
cause important evidence may be elicited in that way as
to the relative position of the assailant and the victim
at the time the firearm was discharged.
With reference to wounds it is also to be noted
that all evidences which tend to warrant any conclus-
ions as to their ante- or post-mortem occurrence must be
carefully studied. Penetrating wounds are not to be
carelessly or indiscriminately probed because of the
great danger of possible rupture of the walls of import-
ant cavities and thus hopelessly complicating the ques-
tion of the extent of the original wound. Careful dis-
section should invariably be employed to determine the
course and the direction of wounds, and occasionally, in
exceptional cases, this can best be done after the cavi-
ties of the body have been opened ;. as a general rule the
external examination should be completed before any
of the cavities of the body are opened, because there-
after turning of the body becomes very undesirable
and the anatomic relations are often quickly disturbed.
The physical and other peculiarities to be taken
note of in the case of unknown persons, have been
Examination of the Body. 48
called to mind on page 10 in connection with the ]x)st-
mortem record.
In medico-legal cases the external inspection may
include an examination of the clothing upon the body
for tears, holes, stains, and also of the premises where
the body was found and the surroundings, for the pur-
pose of discovering, if possible, anything that may
throw some light upon the cause or mode of death.
Particular attention should be paid to the position of
the body with reference to the furniture, to blood
stains, to vomited material; to glasses, powders, or
bottles ; instruments that may be found should be placed
under lock and key for the time being ; any stains upon
the carpet, the bed-clothes, or the personal clothing
may have to be cut out and preseiTed for examination ;
under all circumstances a thorough description is made
of everything observed and a record made of the dis-
position of the articles referred to. In some instances
a photographic view of the room or premises may be
very valuable.
THE ORDER OF THE INTERNAL EXAMINATION.
The order in which the large cavities of the body
may be exaifiined is subject to considerable variation
depending upon the nature of the case and also some-
what upon the place where the examination is made.
In medico-legal cases it is the custom to direct
attention first to that part of the body in which there is
reason to believe that the cause of death will be found
and then to examine the remaining cavities in whatever
order may seem natural or convenient. In certain
44 The Technique of Post-Mortem Examination.
cases it may be advisable to open all the cavities and to
display such organs as the heart and the brain prior to
incision or removal in order that they may be examined
as nearly simultaneously as possible with reference to
the amount of blood contained in them. This should
be done in order to avoid possible disputes as to the
effect upon the amount of blood in either organ the
removal of one before the other might have. It is fre-
quently stated that the cutting of the large veins at the
base of the heart disturbs the quantity of blood in the
brain and its membranes; this quantity is largely
dependent on post-mortem circumstances, however, and
the cutting of the large veins does not in any way alter
the amount of free fluid in the encephalic and cranial
cavities ; so that, as far as the quantity of blood is con-
cerned, it really seems to be a matter of but little
importance which part is examined first, except that in
order to avoid unprofitable contentions it may be well
in specially selected instances to expose the contents of
all the cavities before removing any of the organs.
In ordinary cases the most frequent order of
examination should be from above downward, viz.,
cranial, thoracic, and abdominal cavities. Often, how-
ever, the suspected existence of grave lesions within the
organs in the latter cavities will change the order.
It will be seen a little later on that while the abdomen
is opened before the thorax, yet it is examined later.
In case the spinal cord is to be removed, then it
would be advisable to do so the very first thing or
immediately after the removal of the brain, in case
the post-mortem examination is made at a private resi-
Examination of the Body. 45
dence, because to turn the body over on the anterior
surface after haying opened and examined the thorax
and abdomen is under all circumstances a very uncleanly
procedure. In a hospital post-mortem room this objec-
tion is in the main removed on account of the specially
constructed tables, and the cord might as well be re-
moved during the latter as during the early part of the
autopsy, but the intimate physiologic relation between
the brain and the cord demand that under all circum-
stances their examination be as connected as jx)88ible.
In medico-legal cases turning of the body might modify
the relative position of parts, as in the case of incised
wounds, and for this reason the vertebral canal might
best be left to the last in such instances.
From these fragmentary considerations it will be
observed that no set rules can be laid down as to the
order of the examination ; in the individual ordinary or
medico-legal case the order should be such as would
cause least disturbance in the parts that remain.
"The individuality of the case must often deter-
mine the plan of the examination, but we must not
begin with individualizing nor make a rule of the excep
tions."
THE SPINAL CANAL.
The body lies prone, the neck and upper chest
resting on a wooden block. A continuous incision is
made from the occipital protuberance along the spines
down upon the sacrum, and the skin and subcutaneous
tissue is then dissected loose for a short distance on
each side of the median line. Deep incisions are now
46 The Technique of Post-Mortem Examination.
made through the muscles and the fascia attached to
the spines and all soft tissues are dissected away from
the laminse out to the articular processes so that the
vertebral arches are fully exposed. Morbid conditions
of the soft parts and fractures of the bones can now be
looked for. The laminse are next sawn through near
the articular processes, so as to open the spinal cavity
at its outer borders; with Luer's rhachitome, the adjust-
able, double-bladed vertebral saw, this is quite readily
accomplished simultaneously on both sides, the distance
between the saw blades being regulated so as to fit the
individual spine. A single-bladed saw, curved and
round at the point (Fig 7.) accomplishes the same
result with a little more labor, but with a somewhat
greater degree of safety to the integrity of the cord, as
the double saw will be found liable to impaction in the
saw grooves in the curved regions of the spine and the
sudden jerks and thrusts applied in order to loosen it
may force the blades down upon the dura or the cord
with more or less injury to the latter. The entire
posterior archway should be sawed through completely
so that every spinous process yields readily to manual
pressure or traction, and this should be fully accom-
plished without the use of any of the various forms of
chisels or of bone pliers recommended for the purpose
of hastening the removal of the cord; then the liga-
mentous structures betwee^ the atlas and the occipital
bone are cut across, and the entire loosened posterior
arches held together by the ligamenta subflava may be
removed at once with a strong forceps or hook: or the
removal may be commenced in a similar way from below.
Examination of the Body. 47
The use of the mallet and chisel or of cutting
bone forceps in opening the spinal canal for tlu* pur-
pose of removing the spinal cord cannot ]>e recom-
mended any longer because Van Gieseii* has recently
shown in a very thorough manner the great dant^cr of
mechanical disturbances in the cord substance wlion
such violent procedures are resorted to. He has (|uit«^
conclusively demonstrated that autopsy bruises and jars
may cause topographic alterations and dispersions in
the gray and white matters of the spinal cord, as well
as minute structural changes, and that a nunibei' of the
cases described in the literature as instances of hetero-
topia, or malformation of the cord, are in reality only
the result of mechanic disturbances due to fnultv
•
post-mortem technique. When the Inniina) an» com-
pletely sawed through and theconncH'ied posterior nrch-
way torn off in the manner above iii(licat(Ml, then tin*
liability of extensive as well as deceptive^ artefacts due
to bruises and jars is reduced to a minimum; the smw
may, of course, be driven through the lamina' and
against the dural sac, but with a properly shaped saw,
carefully handled, the chances of injury to th(> cord
must be considered very slight as compared with the
chisel and hammer procedure.
The spinal cord can also be taken out aft(M- tln^
removal of the vertebral bodies by means of Hrun(4ti's
chisels (Fig. 10), the pointed guard of which is inserted
into the vertebral canal between two pedicles against the
upper one of which the cutting edge rests, the long axis
^Ira Van Giesen, A Stiidy of (he Artefacts of the Nervous System.
Appleton & Co., 1892.
4S The TEcrofiQUE or Post-Mortem Exasoxatios.
parallel
pedicles are then ent off on both sides bv means of blows
from the mallet. In this way the spinal cord is expe-
ditiously removed through the long anterior incision
into the body after the organs have been taken out, and
the method may therefore be of advantage in limited
or private autopsies, but there remains the danger of
mechanic damage to the cord-
THE SPINAL CORD AND COLr^IN.
After the removal of the arches the posterior sur-
face of the dura and the condition of the spinal canal
as to abnormal contents can be studied. The dura may
now. if so desired, be incised by means of probe-pointed
scissors along the median line posteriorly, and the sub-
dural space as well as the pia can then be inspected
and the consistence of the cord carefully estimated by
means of gentle palpation with the finger. On
account of the greater danger of damage to the cord
under these circumstances, it is best to always remove
it T^-ithin the intact dural sac whose attachments to the
bony walls of the spinal canal are very loose. The
spinal nerves are first cut across with a long, sharp-
pointed, thin-bladed knife as far into the intervertebral
foramina and away from the dura as possible. Dividing
the branches of the cauda equina, the lower end of the
cord is then carefully loosened from its bed and lifted
up by means of a pair of forceps pinching a fold of
the dura, and while the left hand holds the cord out of
the way in this manner, the right severs the anterior
attachments between the dura and the canal. Lastly,
Examination of the Body. 49
the cord and the dura are cut across as near the occip-
ital foramen as possible, or they may simply be
extracted, in case the brain has already been removed.
In the latter instance it must not be forgotten to cut
the dura across just below its attachment to the margins
of the foramen magnum.
During these manipulations great care must be
exercised not to bend, twist or compress the cord, which
should not be grasped directly, but always by means
of forceps pinching up a fold in the dura. After its
removal place it upon a smooth board of suitable length
with, let us say, the posterior surface downward. The
dura is now carefully incised along the median line
anteriorly, and the contents of the subdural space, the
inner surface of the dura, and the pia examined; then
the cord may be gently turned over and the same pro-
cess repeated as regards the posterior pari The dura
is then removed from the cord by cutting with sharp
scissors the spinal nerves and the ligamenta denticulata
on each side.
The further treatment of the cord will depend
upon the purpose of the examination. If it be intended
to make a thorough histologic study, then the pur-
poses of such investigation will undoubtedly, in the
majority of instances, be best subserved by at once
suspending the cord in the long glass jars usually pro-
vided for this purpose, filled with bichromate solution.
A small weight may be attached to the cauda equina,
in order to maintain the cord in a perfectly straight
position. Palpation and incision should be studiously
avoided in :thes<e instg-iice^, especially where foci of
50 The Technique of Post-Mortem Examination.
softening of various kinds are thought to exist, in
order that artificial displacements and bruises can be
entirely eliminated; the examiner must be content with
inspecting the cut surface of the upper extremity.
On the other hand, if it be concluded to examine
the cord substance macroscopically first, and perhaps
to prepare for microscopic study such parts as may
subsequently be selected for various reasons, then
the whole length of the spinal cord may be gently
and delicately palpated with the clean index finger,
in order to estimate, if possible, variations in con-
sistence, foci of softening or of sclerosis. Then it is
cut into transverse sections, say one inch in length,
with one stroke of a moist, sharp razor or thin scalpel,
which leaves the segments attached to the pia; the
knife should be moistened before each cut, and care
should be taken not to compress the cord as the sections
are made, so as to avoid bruising the cord as well as to
prevent the myeline from running out upon the surface
to any greater extent than is absolutely necessary; cords
in which foci of softening are detected by palpation
ought not to be incised at all in the damaged regions,
if microscopic examination be determined upon, because
if incised the softened substance may flow out to such
an extent as to completely disturb the topographic
arrangements.
The condition of the columns of white, and the
horns of grey matter, the central canal, and a variety
of morbid lesions can be made out fairly well upon
the cut surfaces of the cord of good consistence,
exposed in the way inciicated, but it is to be recollected
Examination of the Body. 51
that the naked eye examination of this organ is, after
all, somewhat unsatisfactory and never to be solely
relied upon. If the cord is to be hardened after having
been divided into segments, then place it upon a
quantity of absorbent cotton, in a wide jar, so that it
rests in an easy coil which exposes the cut surfaces to
the action of the fluid; during the early process of
hardening more myeline may be driven out upon the
free surfaces of the segments.
Moderate traction upon the intact dura will usually
lift the spinal ganglia out of the intervertebral for-
amina so as to permit of their removal in connection
with the spinal nerves ; chiselling away of the articular
processes after removing the cord renders the ganglia
readily accessible, and their removal free from danger
of injury.
After the removal of the cord the structures com-
posing the canal can be examined for fractures, dis-
placements, morbid processes of various kind; some-
times, in order to study the exact location of fractures
or other lesions, it may be necessary to remove a seg-
ment of the spinal column itself, which is quite readily
accomplished by cutting through the intervertebral
cartilages above and below the portion to be removed,
then dissecting away the soft parts thoroughly, severing
the bony connections by the judicious aid of the ham-
mer and chisel or saw.
THE COVERINGS OF THE CRANIAL CAVITY.
The body is supine, the head at the end of the
table, the neck and occiput rest on a block which
52 The Technique of Post-Mortem Examination.
brings the head well forward. The hair, especially
when long as in women, should be carefully parted
along the line of the proposed incision which runs from
the apex of the mastoid process behind one ear over
the vertex to a corresponding point on the opposite side.
This incision is to be made with a heavy knife, one
firm stroke of which divides the soft parts clear down
to the bone (Fig. 14). It has been recommended,
after transfixion of the soft parts, to cut outwards in
order to save the edge of the knife and in order to cut
off as little hair as possible. In medico-legal cases,
with injury to the scalp, the incision should avoid such
wounds as much as possible so as not to interfere with
measurements or localization. The division of the soft
parts should be especially complete at the beginning
and at the end of the incision, because at these points
the soft parts are intimately adherent to the bone, and
if not loosened thoroughly the scalp cannot be easily
reflected. The scalp is now reflected by dissection, by
traction, and by pushing with a chisel inserted between
the skull and the pericranium, anteriorly as far as the
supra- orbital ridges, posteriorly down to the external
occipital protuberance, and laterally down to the
external auditory canals, the scalp being folded upon
the face and underneath the occiput. The soft parts
may be reflected only down to the pericranium, in case
there is reason to expect morbid changes in the peri-
osteum and the bone; after examination it can be
scraped off with a chisel or it can be divided down the
bone along the line of the proposed saw incision for
removal of the vault. The temporal muscles are to be
Examination of the Body. 53
left intact beneath their fascia, but divided down to the
skull in the line of the incision referred to.
The surfaces thus exposed are to be carefully
examined for traumatic lesions, hemorrhage and the
various forms of inflammation. The external surface
of every skull always merits a conscientious study in
regard to premature synostosis or persistence of the
sutures, supernumerary bones, asymmetery, as well as
the various special morbid conditions. Two diameters
should always be taken of the skull, namely the
transverse and the longitudinal; in the mesocephalic
skull the ratio of the transverse diameter to the
antero-posterior is as 70-80 to 100; if the transverse
diameter be less, then the skull is known as dolicho-
cephalic; if it be more it is called brachycephalic ;
abnormally shaped skulls will thus be recognized and
measured. By applying strips of lead to the surface
of the skull, the various outlines may be taken and
transferred to paper; there are three principal outlines:
the one in the greatest circumference in a line with the
center of the forehead and the occipital protuberance ;
the second from root of nose to occiput; the third from
one mastoid process to the other.
The skull cap is now removed by means of the
saw; the incision should follow a line which runs on
both sides from the centre of the forehead to the base
of the mastoid process and from these points backward
and upward to a point a little above the external occip-
ital protuberance, thus separating a wedge-shaped sec-
tion of the calvaria ; the temporal fascia and muscles
are divided with the knife in the line of this incision ;
54 The Technique of Post- Mortem Examination.
when the skull cap is removed in this way it is easier
held in place again by means of a suture or two in the
temporal aponeurosis and thus undesirable disfigure-
ment of the corpse is readily avoided. Otherwise the
incision may be circular, running from the glabella to
the occipital protuberance on each side; this skull-cap
can be held in place by means of sutures passed through
drill holes or by means of double-headed carpet tacks.
While sawing with the right hand the left hand
applied to the face steadies the head which is twisted
from side to side as convenience demands ; while sawing
posteriorly it may be necessary to stoop down as the
field cannot always be brought into view otherwise ; the
saw furrow should be continuous and even, and the brain
inust not be injured. The average thickness of the
skull is about 0.3 cm., thinnest at the temples and in the
temporal fossae, thickest at the occiput; the sawdust
from the external table is white, from the diplOe red,
and white again from the internal table; as the skull is
cut through there is a sudden sense of diminished
resistance; by bearing these points in mind it will be
possible to guard against brain injury.
In medico-legal cases the skull should be sawed
completely through all around so as to avoid entirely
the use of the chisel and mallet which might produce,
or be alleged to produce, misleading fractures. In
clinical cases the calvaria may be cracked ofif with the
cautious use of the chisel and hammer after sawing
partially through the bone. The saw incisions should
meet accurately as fractures are most readily produced
at the points where the ends fail to meet.
Examination of the Body. 55
The calvaria is usually easily loosened by inserting
a chisel or cross-bar between the sawcut margins and
twisting them on their long axes, after which a blunt
hook may be inserted, preferably posteriorly, and the
cap suddenly jerked away from the dura ; it is danger-
ous to use the fingers for this purpose as skin abrasions
and scratches may result.
If the dura be so unusually and so firmly adherent
to the inner surface of the skull that traction seems
likely to cause injury to the brain, then the dura must
be divided with probe-pointed scissors along the skull
incision and, after cutting the falx cerebri across near
its anterior attachment, the skull-cap and dura are
removed together; this method must always be used
in children under seven years of age, because up
to that time the dura is firmly attached to the bone
as its internal periosteum. In these instances of normal
or pathologic adhesions of the dura, it can usually be
torn away after removing the skull-cap ; it happens, how-
ever, that sometimes it cannot be torn away, and then
the longitudinal sinus must be incised with the dura
attached to the bone. Ordinarily the calvaria comes
away readily enough, leaving the dura covering the brain.
The sawn edges, the relative thickness of the outer
and inner tables and the diploe, the condition of the
inner surface of the skull can now be examined in all
necessary detail (Fig. 14).
The external surface of the dura is next examined ;
its color, the condition of its vessels, the presence of
Pacchionian bodies upon the external surface, etc., are
points to be noted as well as the morbid changes that
r
Tifi The Tkchuwue of Post-Mortkm Examination.
may be present. The ilegrep of tensioii should always
be tested by piucliing np a fold near the apex of the
frontal lobee; with the body oq the lack it ehonld be
possible to raise a sninll fold in the locality indicated;
if a large fold is easily picked up, then the intracranial
contents are diminished, while if no fold at all can be
made, there is increnKLxl cereliral pressure. The longi-
1
1
tudinal sinus is now to be incised with Bcissors or with
a small knife, the dura on each aide being stretched by
the fingers of the left hand, in order that its contents
and the condition of its lining may be examined.
The nest step consists in dividing the dura on
each side near the sawn edge of the skull from the
anterior to the posterior extremity of the falx cerebri;
1
Examination of the Body. 57
this can be done with a thin, narrow-pointed knife,
or with small probe-pointed scissors, care being
taken not to piiincture the pia; the dura over each half
of the convexity is then folded in turn over upon the
opposite half so as to expose the under surface to full
view and examination; at this time the condition of the
subdural space with reference to abnormal contents as
well as the color and vascularity of the pia over the
convexity, always comparing the two sides, are to b®
carefully noted; if adhesions be found between the
dura and the pia, then the corresponding dural area
should be cut awav from the membrane and allowed to
remain adherent to the pia instead of being separated
forcibly with perhaps such' damage to the subjacent
cortex as to render a histologic examination useless.
In order to sever the anterior attachment of the
f alx to the crista galli preliminary to removing the brain,
a narrow, sharp knife is passed down parallel with and
to the left of the f alx with the edge forward until the
point rests upon the cribriform plate ; then the edge is
turned to the right and, as the dura is made tense by
drawing it upward and backward with the left hand, the
falx is cut across; the edge is then turned forward
again so as not to cut into or contuse the brain on with-
drawing the knife; there will be felt a giving way of
all resistance as the falx is completely severed. The
dura may be left attached to the brain during its
removal, or it may be gradually and carefully torn away
from its adhesions to the pia by means of the Pacchio-
nian granulations and the superior cerebral veins on
each side of the longitudinal fissure and left hanging
58 The Technique of Post -Mortem Examination.
down at the occiput; if it be intended to inject the
brain, then the dural covering of the hemispheres had
best be left in situ so as not to disturb the pial veins as
they enter the longitudinal sinus.
REMOVAL AND EXTERNAL EXAMINATION
OF THE BRAIN.
Place the block under the neck so that the head
hangs backward just a little; carefully pass the fingers
of the left hand between the skull and the frontal lobes
and gently draw these backward so that the olfactory
bulbs are brought into view; as the brain mass now
slowly leaves the cranial cavity by its own weight,
resting all the while in the left hand, the optic nerves
are divided at their foramina, the internal carotid ves-
sels are cut across as they penetrate the dura, and
the hypophysis and nerve trunks that successively come
into view are severed as near the dura as possible, with
a narrow-pointed knife that always cuts against the bone
so as not to injure the brain; the temporo- sphenoidal
lobes are lifted out of the middle fossye and the tento-
rium, which has now been reached, is to be cut with
the point of the knife, precisely at its attachment to
the superior margin of the i^etrous portion of the tem-
poral bone commencing at the left sinus transversus and
going with a sawing motion inward to the posterior
clinoid i)rocess, and then, on the right side, outward in
reverse direction; the knife point penetrates the thick-
ness of the tentorium only, and great care is taken not
to cause injury to the cerebellum ; during and after the
division of the tentorium the brain mass is carefully sup-
ported with the left hand so as to prevent laceration of
Examination of the Body. 59
the base from its own weight, as the only natural sup-
port it can now have comes from its connection with the
spinal cord. The numerous nerve trunks about the
pons-meduUa transition are now cut as near their exit as
possible, and finally it only remains to divide the
spinal cord and the vertebral arteries as far down in
the spinal canal as possible; for this pm'pose the knife
is passed down with its edge to one side and the cord is
severed by means of one decisive stroke accompanied
with elevation of the handle of the knife so as to make
the division at as near a right-angle as possible ; the ver-
tebral arteries are to be cut on each side. In order to
secure vertical cut surfaces where the cord is divided,
which may be very desirable for the purpose of the
microscopic examination, the myelotom of Pick may be
used to very good advantage (Fig 15). If the cord has
LAMPS' 5 Mp-tt^
Fig. 15.— Pick's myelotom.
already been removed, then it may be necessary to sim-
ply divide the vessels and the nerves on each side of the
remaining portion, which is then extracted through the
foramen magnum as the brain is raised from its cavity.
All the structures that are connected with the
brain have now been severed, and while the left hand
supports it as before the fingers of the right are placed
upon the inferior surface of the cerebellum so that the
medulla rests between them, and the whole mass is then
lifted bodily out of the cranial cavity; if the dura has
been left upon the upper surface, then it is divided
with scissors at the occiput. The base of the skull is
00 The Technique of Post-Mortem Examination.
now examined for abnormal contents and any free fluid
may be collected or estimated as to quantity.
If the brain is to be injected and hardened before
its interior is examined, then the organ should be first
weighed and its various surfaces carefully inspected
while it is yet fresh and before the commencement of
any of those more elaborate procedures necessary in
order to produce a successful and instructive hardened
specimen. The pia should not be lacerated at any
point and a special attempt should be made to leave the
vessels at the base as long as possible in the brains
which it is proposed to inject and harden; means for
he commencement of these processes must be close at
hand, and the brain, while fresh, must be carefully
guarded against contusion and distortion if it is neces-
sary to transport it for some distance.
If the brain is to be cut open immediately after its
removal, it is first weighed and then placed base upward
upon a smooth, firm, easily movable tray or board of
considerable extent, and the lateral and basal pial sur-
faces carefully examined together with the cranial nerves
and the vessels at the base.
The arteries at the base and in the Sylvian fissures
require careful, routine examination on account of the
comparatively frequent occurrence of important changes
such as arterio-sclerosis, embolism, thrombosis, aneu-
risms, etc.; consequently the pia-arachnoid covering
them should be picked off, and the layer of arachnoid
which bridges the Sylvian fissures should be incised
and the temporo-sphenoidal separated with the fingers
from the parietal lobes so as to expose the middle
Eyxmination of the Body. 61
cerebral arteries throughout their whole course; the
frontal lobes should be separated so as to bring to
view the anterior cerebral vessels as they curve over
the corpus callosum; the posterior cerebral arteries
are also to be traced backward between the cerebellum
and the occipital lobes. All the arteries should be
opened longitudinally as far as possible with fine scis-
sors so that the interior can be completely examined.
Having thoroughly finished the examination at the
base, the brain is turned over and a systematic study
made of the general contour, fissure formation and
peculiarities of the cerebral surface.
Eemoval of the pia is indicated whenever it is
4esired to determine whether or not it is abnormally
adherent to the brain surface, in order to study the
size and form of the convolutions and also in order
to facilitate accurate localization, because it is rather
difficult to trace the gyri and fissures while covered
with this membrane. It must be recollected, however,
that the pia should not be stripped away from those
parts of the cortex that are to be examined micros-
copically because of the large number of pial vessels
that enter and leave the brain, the tearing out of which
necessarily disturbs the cortical structure considerably.
Small portions should consequently be removed for
microscopic examination with the pia still adherent.
In order to remove the pia the artery of the
corpus callosum is cut across in front and at the
posterior border, the intermediate portion is to be
grasped with forceps and the pia detached slowly and
carefully, little by little ; when the convexity is reached
02 The Technique of Post-Mortem Examination.
the free membrane may be grasped with one hand
which continues the stripping while the other hand
pushes the brain away from the pia; should the pia
tear at any place pick it ap again with forceps at the
bottom of a sulcus in which run the larger and stronger
vessels. A stream of water running gently over the
brain will assist the removal greatly.
On removing an adherent pia a layer of cortical
substance will remain attached to it; in order to accu-
rately localize such a district and in order to preserve
it for microscopic examination the pia may be detached
on all sides up to the margin of the adhesion, over
which it can be left undisturbed.
After removal of the pia the general form of the
convolutions, whether broad or narrow, flattened or
sliarp, surface depressions and discoloration s, areas of
cortical softening, of large and small hemorrhages, and
a number of other lesions are readily studied.
SECTION OF THE BEAIN.
The method of sectioning the brain will vary
according as the object of the examination varies. If
the case is a medico-legal one and it is necessary to
determine at once and positively the presence or absence
within the brain of actual or contributing causes of
death, then the somewhat mutilating method of Vir-
chow, or some slight modification thereof, may be em-
ployed to good advantage. By this method the brain
mass may be sufficently subdivided to discover even
quite minute macroscopic lesions while the topographic
relations are fairly well maintained.
I
Examination of the Body. 63
A brain divided after Virchow's directions cannot,
however, be subjected with any degree of success to
the modern methods of fixation and hardening for the
purpose of studying degeneration tracts, etc., because
the dissection is too mutilating.
When it is not necessary to minutely subdivide
the brain, then the method of hardening in toto in
Mtiller's fluid and subsequent division into a number
of transverse sections, as advocated by Hamilton, may
be employed if the space and necessary apparatus for
continuous injection be at hand.
Otherwise Meynert's method affords an opportunity
to study all the more important structures while the
brain is divided into parts which are suitable for fixation
and hardening at the same time preserving the topo-
graphic relations.
ViRCHOw's Method (Modified). — The brain lies
base downward (Fig. 16). The left ventricle is usually
opened first and the frontal apex should point away
from the operator. The two hemispheres are care-
fully separated until the corpus callosum is quite
completely exposed. If the brain is at all soft great
care must be used least the corpus callosum falls
apart. Place the left hand on the left hemisphere in
such a manner that the fingers rest upon the superior
and external surface while the thumb is applied to the
median aspect and lift the whole hemisphere a little
out and upward (Fig. 16). Then with a sharp knife
the right hand makes a shallow, vertical incision into
the roof of the ventricle in the angle formed by the
junction of the corpus callosum with the median surface
64 The Technique of Post-Mortem Examination.
of the hemisphere ; this incision is continued backward
and forward the whole length of the corpus callosum,
opening the ventricle fully without any injury to the
floor ; then expose the posterior horn by cutting back-
ward and outward into the occipital lobe, and the ante-
rior cornu by dividing the frontal lobe in a direction a
little outward and forward. Turn the left brain mass a
little outward so as to open the lateral ventricle quite
fully, then connect the two extremities of the incisions
into the frontal and occipital lobes by a nearly vertical
cut which passes through the floor of the ventricle out-
side of the basal ganglia down to the cortex of the
inferior surface, allowing the left hemisphere to fall
outward by its own weight.
On the right side the lateral ventricle is opened and
exposed in the same way after turning the tray around
so that the frontal apex points toward the pathologist.
Both lateral ventricles are now fully opened and
their size, contents and walls are examined ; the choroid
plexuses can be extracted, or if it is desired to open the
middle or descending cornu this can be readily done
by an incision commencing at the opening of the cornu
and extending forward and outward.
The corpus callosum has been carefully maintained
in the median line during these manipulations and it is
now lifted up with the left hand and a knife point enters
through the foramen of Monro, the corpus callosum and
the fornix being divided forward and upward ; the parts
behind this division are raised up and turned back-
ward, leaving the velum interpositum uncovered; after
examination of this structure and its choroid plexuses
Examination of the Body. 65
it is also to be carefully raised up, the large veins that
enter it from the basal ganglia are cut across with a
knife, and the velum is then detached from the pineal
body and the corpora quadrigemina.
The third ventricle is now fully exposed and the
structures forming its walls can be inspected. The
right posterior pillar of the fornix is then divided and
the callosum, the fornix, and the velum interpositum are
placed over to the left of the median line (Fig. 17).
In order to open the fourth ventricle the fingers of
the left hand are placed underneath the pons and the
cerebellum which they support in such a way as to ele-
vate the vermes slightly; then a vertical incision is
made with the right hand as exactly through the centre
of the vermes as is possible, and as the cerebellar
hemispheres fall out to each side by their own weight
the ventricular cavity comes into view, the incision
being carefully prolonged in both directions until the
entire roof of the ventricle is divided and the Sylvian
aqueduct opened; it is well to remember that the roof
of the fourth ventricle is thinner in front than behind.
The whole series of encephalic cavities has now
been opened and they can be examined at leisure with
reference to size, contents, and the condition of the
ependyma. Should the ventricles contain a large
amount of fluid the brain ought to be weighed again
after allowing the liquid to drain away.
The cerebrum is now to be further examined in the
following manner (Fig. 17) : Support the everted left
hemisphere with the left hand, and divide it from before
backward into halves by means of a long vertical incision
06 The Technique op Post-Mortem Examination.
which extends down into the cortex of the under surface
and yet does not completely sever all connections between
the two parts; each resulting wedge-shaped half is
again bisected in the same way, the incisions running
along the upper sharp ridge down to the convex under
surface of the brain mass, which is supported by the
fingers of the left hand, a slight upward movement
serving to make the cut surf aces fall apart; this process
of bisecting is continued until in the judgment of the
examiner the subdivision has reached a sufficient degree
of minuteness, and then the tray is turned and the
right hemisphere is incised in the same manner, but in
the reverse direction, i. c. from behind forward.
These incisions, like all incisions into the brain,
should be made with one long stroke of a sharp, smooth
brain knife, which is rinsed in water between each cut,
so that the surface presented may be clean and smooth,
in order that the degree of vascularity, the relation
between the grey and white matters, and any focal
lesions that may be present can be studied under as
favorable circumstances as possible (Fig. 17).
The basal ganglia, the thalamus and the striate
body may be next examined by means of a number of
transverse incisions which, commencing at the anterior
extremity of the striate bodies, divide the ganglia into
a number of sections, each about 5-7 mm, in thickness;
each cut should be carried through corresponding por-
tions of each ganglion, so that as nearly as possible the
same surfaces may be presented on either side for
comparison. In making these transverse incisions the
fingers of the left hand are placed under the district to
t
t-
Jr
'.1.
i
I
Examination of the Body. 67
be incised, and by an upward movement the cut surfaces
are made to fall apart. The incisions are made with a
moistened knife, one stroke of which from left to right
divides the ganglia down into the cortex of the base of
the brain without completely severing the parts.
The great ganglia are also very frequently laid
open in the direction of their fibres by a series of radi-
ating incisions whose common point of origin is the
cerebral peduncle on each side, whence the cuts radiate
like the sticks of a fan.
The cerebellar hemispheres, already separated
through the centre of the vermes by the opening into
the fourth ventricle, are now further divided by a cut
into each hemisphere which runs from the ventricle
along the middle branch of the arbor vitse down into
the cortex of the convex surface ; each resulting half is
further bisected by incisions which run in the same
direction (Fig. 17).
Now place the left index and middle finger under
the medulla and the pons, so that the spinal cord rests
in the palm of the left hand; raise these structures so
that the cerebellar hemispheres fall to the sides, and
then divide them by a number of transverse incisions
which in turn pass through the corpora quadrigemina,
the peduncles, the medulla, the pons, and the spinal
cord. Or the hemispheres are first folded together like
the leaves of a book, restoring the brain to its normal
shape ; it is then turned on its transverse axis and the
pons, medulla and spinal cord are then cut into thin,
transverse sections from the basal surface; the right
68 The Technique of Post-Mortem Examination.
and left cerebral peduncles may be laid bare and incised
at the same time.
After the section of a brain in this manner the
various parts are still so connected that the brain may
at any time be restored to its normal shape, with its
component structures in their normal relation to each
other; in this way localization of the various lesions is
quite accurately accomplished. The order of procedure
is frequently different from the one followed in the
description. Thus the left hemisphere may be incised
immediately after opening the left lateral ventricle, the
right half after opening the ventricle on the side, and
the ganglia may be incised immediately after the
removal of the callosum and the velum interpositum,
and so forth; but inasmuch as the series of encephalic
cavities are all connected it would seem more natural to
first lay them all open to comprehensive inspection,
after which the brain itself may be cut into in the way
described with equal advantage. It goes without say-
ing that frequently slight variations and modifications
of the classical method described will become necessary
on account of the peculiarities of the individual case
as well as the purpose for which the examination may
be made.
The Transverse Section Method of Pitres and
Hamilton. There are, of course, many and valid
objections to minutely subdividing all brains according
to the method known as Virchow's.
Gross or system lesions may be known to exist,
the nature, the exact extent and seat of which it may be
important to determine accurately at the same time
Examination of the Body. 69
permanent preparations are made. For this and simi-
lar purposes the method of dividing the fore-brain into
a number of transverse segments introduced by Pitres,
modified and advocated by Hamilton, will be found use-
ful and satisfactory. This method can be applied to
fi'esh and preferably to brains hardened in Mtiller's
fluid.
The first step consists in removing the pons,
medulla and cerebellum by a transverse incision into
the crura cerebri at the middle ; these detached struc-
tures can be incised, if desired, in the manner already
detailed after first opening the fourth ventricle through
the vermes, then dividing and subdividing the cerebel-
lar hemispheres into halves, and finally carrying a pro-
gressive series of transverse incisions through the
pons, medulla, and cord.
In order to fix the brain-mantle in one definite
position, it is recommended by Hamilton to place it
vertex downward upon a board with the tips of the
frontal and occipital lobes in a horizontal line perpen-
dicularlv to which a number of transverse sections are
made.
According to Pitres' original method the sections
ran parallel to the fissure of Rolando and were conse-
quently not transverse to the long brain axis.
According to Hamilton's plan Section I runs
through the anterior half of the third frontal convolu-
tion; Section II passes through the tip of the temporo-
sphenoidal lobe and the operculum; Section III is made
immediately in front of the optic chiasm ; Section IV
runs through the inf undibulum ; Section V traverses the
70 The TEcHsiyrE of Post-Mortem Examination.
corpus albicans; Set-tiou VI passes through the anterior
margin of the pons, aud the Vllth and last .Section mus
across the front of the augular gyrus (Fig. 18).
The prefrontfti section of Pitrea passes through
the anterior half of the third frontal convolution, the
peilicuU")- frontal section runs 2 ctiu. in front of the fis-
f-.t- !•*■ Pc-rpendic.ulflrlriine>-pv>.eBpr1limoIliiin!iinljrHln, BeL-Uon
sure of Rolando; the frontal section divides the ascend-
ing frontal convolution ; the parietal section bisects the
ascending parietal convolution; the jjediculo- parietal
section passes 3 dm. l)ehind the fissure oE Holando; the
occipital section cuts across the occipital lobe. On
each section the white substance is divided into definite
Examination of the Body. 71
areas, known as fasciculi with distinct names which
may be used in the descriptions of lesions, thus facilitat-
ing accuracy of observation, and such sections made
according to either of these plans, hardened and
mounted, make instructive and beautiful permanent
specimens (Fig. 18 and 19).
Meynert's Method. The object of this method,
which has been extensively adopted by neurologists and
in insane hospitals, seems to have been to determine
the relative weight of the brain mantle, the brain axis,
and the cerebellum at the same that an excellent topo-
graphic view of the various tracts and coarser struc-
tures is obtained. This plan allows inspection with the
eye of all the more important parts in the fresh speci-
men and the topographic relations are so maintained
that fixation and hardening will produce valuable pre-
parations. The following description is introduced
verbatim from Blackburn's ^'Manual of Autopsies ^^
Designed for the Use of Hospitals for the Insane, 1892:
" The section is sometimes slightly modified from
the original plan of Meynert; it may be made as fol-
lows: .
"The brain is placed with its base upward and the
cerebellar end toward the operator. The cerebellum
is lifted up and the pia mater is cut through above the
corpora quadrigemina, around the crura, and along the
inner margins of the temporal lobes until the middle
cerebral arteries are reached. The Sylvian fissures are
now opened to their entire extent, the opercula are
raised and the insular lobes exposed to their limiting
furrows.
Examination of the Body. 73
"The apices of the temporal lobes are now raised,
and with the knife held nearly horizontally, their junc-
tion with the base is cut through until the anterior
extremities of the descending comua are opened. The
knife is now inserted into the descending horn, and the
incision is carried backward as far as the posterior
angle of the insula, or even some distance beyond it,
severing some of the convolutions at the posterior
extremity of the Sylvian fissure.
"The next incision is made to separate the basal
piece from the posterior extremities of the frontal lobes.
It connects the anterior boundaries of the islands, and
opens the anterior horns of the ventricles. The incis-
ion may be a slightly curved, transverse one, connecting
the anterior borders of the islands; or by a little care
and a double-crescentic cut the exact boundaries of the
convolutions may be followed.
" The cerebellum is now raised and the knife is
entered at the posterior angle of the island, and the
incision is carried along the outer limiting furrow until
it meets the cut previously made through the anterior
border. Care must be taken to keep the knife in the
angle between the roof of the ventricle and the basal
ganglia, to avoid injuring the latter. The basal piece
is now lifted until the anterior crura of the fornix and
the septum lucidum may be severed, and the basal sec-
tion thereby completed (Fig. 20.).
"The basal piece thus separated includes the islands
of Reil, the basal ganglia, the crura, pons, medulla, and
cerebellum. The brain-mantle includes the convolutions,
the corpus callosum and fornix, and the olfactory tracts.
Examination of the Body. 75
" The cerebellum may be separated from the brain -
axis by cutting through its peduncles, and the lobes
may be incised as in other methods. The basal gang-
lia, pons, and medulla are best examined by transverse
incisions. . The brain-mantle may be incised, if desired,
by Pitres' method, or hardened without further section."
THE BASE OF THE SKULL.
The sinuses at the base of the skull are opened
in situ with a knife or scissors and their interior closely
examined. Special attention is to be given the trans-
verse, the cavernous, and the petrosal sinuses on account
of their liability to show changes secondary to middle
ear disease or mastoid necrosis.
The hypophysis cerebri (pituitary body) is care-
fully dissected out of the sella turcica after a suflficient
circular incision has been made into the dura. The
dura lining the fossse of the base is now torn away
from the bones by means of dissecting forceps and the
fingers. The removal of the dura permits ready diflfer-
entiation between actual fractures and misleading fur-
rows and suture lines upon the floor of the cranium.
In cases of meningitis the processes of the dura
that extend into the various foramina and canals and
in this way communicate with extra-dural cavities must
be carefully examined. All the adjacent cavities, the
ear and the mastoid cells, the frontal, the ethmoid and
the sphenoid sinuses, the orbits and the nose must also
be inspected for primary disease foci. The sinuses may
be opened by simply chiselling away their roofs, or
76 The Technique of Post-Mortem Examination.
they can be examined in the course of the more
elaborate proceedings about to be detailed.
THE ORBITS.
The roof of the orbit can be chiselled away very
easily on account of its extreme thinness and its
contents thoroughly examined without any anterior
deformity; the posterior half of the globe of the eye
can be cut away with the scissors and the interesting
changes in the choroid and retina observed in many
diseases can be studied nicely and at leisure; the
anterior portion of the eye can be kept in place by
plugging the orbit with cotton. When there is no
objection on account of cosmetic reasons the eyeball can
of course be enucleated through the palpebral fissure.
THE EARS.
The easiest method of removing the ear in toto
consists in loosening the whole petrous portion by
two saw cuts which meet at its apex; the external ear,
surrounding scalp and muscles are first dissected away
from the bone and externally the saw cuts diverge
sufficiently to include the mastoid cells (Fig. 21). The
ear can now be dissected at leisure according to any
of the methods described for this purpose in special
works (Politzer), a ready way being to place the mass
in a vise and saw it clear through from the posterior
border of the external to the anterior border of the
internal auditory canal. The ear can be examined well
in loco by carefully chiselling away the roof of the
tympanum, going back sufficiently to open the mastoid
cells.
78 The Technique of Post-Mortem Examination.
THE NASAL CAVITY.
In order to examine the nasal cavity the ethmoid
bone and attached parts are to be removed by means
of saw cuts through the bone on either side, com-
mencing in the foramen magnum and extending for-
ward into the frontal bone, the bone between the
anterior ends of the two saw tracks being cut across.
These cuts are best made with a so-called keyhole
saw. The mass is then grasped with bone forceps
and twisted loose, the soft parts being severed with
a knife.
Should only the anterior nares be examined, this
is readily accomplished by separating the upper lip
from the bone and then severing the cartilaginous sep-
tum, removing as much thereof as required.
In some cases it may be deemed advisable to
remove the organs of hearing in connection with the
naso-pharynx ; then two vertical drill holes are to be
made, one in each frontal fossa, 1 cm. to the right and
to the left of the crista galli, passing through the nasal
cavity and through the hard palate ; a narrow key-hole,
saw is then passed through the right of these canals and
an incision is made backward through the anterior fossa
to the middle of the posterior margin of the lesser
wiijg of the sphenoid; from this point the incision is
continued through the middle fossa in the shape of a
curve with the convexity outward so as to cut through
the greater sphenoidal wing, the squamous portion of
the temporal including the glenoid fossa and the tem-
poro-maxillary articulation, through the middle of the
Examination of the Body. 79
bony auditory canal to a point which corresponds to the
junction of the petrosal and transverse sinuses, whence
the incision is continued onward and forward through
the jugular foramen, through the basilar process,
describing the same curve through the left middle and
anterior fossae as through the right, stopping at the
drill hole to the left of the crista galli which is then
united with the one on the right by means of a trans-
verse cut (Fig. 21). This mass is now loosened by
means of a broad chisel, and as it is lifted up with a
forceps grasping the sella turcica, a strong, sharp scalpel
divides the posterior and lateral walls of the pharynx,
the capsules of the temporo-maxillary joints and all
other muscular and fibrous connections.
In order to expose to view the upper air passages
(nasal, pharyngeal, laryngeal and accessory cavities)
Harke* recommends the following ready procedure:
After removing the brain in the ordinary manner,
the soft parts are reflected anteriorly down to the root
of the nose, posteriorly down below the foramen
magnum. Then the floor of skull is divided in the
median line by means of a keyhole saw from the nasal
bones in front to the occipital foramen behind, keeping
as nearly as possible in the median line. Now the two
skull halves are separated by means of a broad chisel
and a mallet, and as the nasal and pharyngeal cavities
come into view, the pieces of mucous membrane may be
cut across with the knife or scissors so as to prevent
further tearing. With the hammer and the chisel the
* Berliner KL Wochenschn'ftj 1892, No. 30.
80 The Technique of Post-Mobtem Examination.
axis may be divided. The two halves of the skull are
still connected by the nasal bones, the maxillary process
of the upper jaw and the bony palate; strong traction
will separate these bony connections without injury to
the soft parts and the lateral halves of the skull and
spine will yield suflficiently to permit inspection of the
tract clear down to the vocal cords. Usually the
median incision passes a little to one side, but the
partitions between the accessory cavities are readily cut
away with strong scissors; the maxillary sinuses as
well as the frontal, sphenoid and ethmoid cavities are
also easily opened from the median surfaces.
THE FACE.
The ends of the transverse incision over the head
may be prolonged down upon the neck and then the
external ear and skin may be dissected loose in a
forward direction so as to expose the parotid regions.
In order to examine the anterior portions of the nasal
cavities the upper lip may be loosened from the bones.
In cases of fractures, injuries and diseases of the bones
of the face the mode of examination will vary much,
depending upon the nature of the case. Removal of
the larynx, pharynx and tongue from below (soon to be
described) will greatly facilitate correct observations of
lesions of various kinds about the face and the adjacent
cavities.
THE LONG ANTERIOR INCISION.
The body lies on the back and the head should
hang over the end of the table so as to bring the neck
well forward. The physician should stand to the right
Examination of the Body. 81
of the body, and grasping the section knife firmly in
the hand, a long incision is made in the median line
from the chin to the pubes, passing in a gentle curve
to the left of the navel so as to leave the round ligament
of the liver intact. This incision is best made with the
whole edge of the section knife, which is held as nearly
horizontally as possible, as the whole length of the pri-
mary incision is made with one continuous stroke. In
emaciated bodies the larynx is very prominent and care
must be used not to wound it while dividing the atten-
uated cutaneous covering. In many instances it may
become necessary to begin the incision at some point
below the chin in order that no external disfigurement
of the body shall be visible or conspicuous (Fig. 22).
The deep depression above the top of the sternum
is readily obliterated by putting the skin on the
stretch between the thumb and index-finger of the
left hand, so as to avoid using the point of the
knife.
The soft covering of the thorax is at once cut
through to the bone while over the abdomen the pri-
mary incision only extends into the muscular layers of
the wall ; in men the lower end of the incision termi-
nates at the root of the penis ; in women near the ante-
rior commissure.
An opening is now carefully made into the abdo-
minal cavity, just below the ensiform cartilage; two
fingers are then introduced into the cavity which lift
the anterior wall well away from the intestines and as
the fingers are spread apart, the volar surfaces pointing
towards the pelvis, the tissues are divided between them
8-2
The Techniqee of Post-Mobtem Examisation,
down to and upon the pubic symphysis; or the margin
on the right side of the incision into the cavity may be
grasped witli the left hand which in this way brings
the wall away from the viscera while the division is
fompleted dowii to the symphysis.
In order to turn the abdominal walls more readily
away to the side the recti musclee may be divided Bub-
Rutaneously near their attachment to the pubes; in this
way more room is obtained ( Fig. 22 ] .
On opening the peritoneum the escape of giis or of
fluid should be noted, and the latter, if possible, col-
lected at once in order that the total quantity may be
accurately measui'ed, if so desired. Should the abdo-
minal cavity contain an excessively large amount of
free fluid, then it may be best for reasons of cleanli-
ness as well as for other purposes, to bail out a con-
Examination of the Body. 83
siderable quantity immediately after making a small
opening into the peritoneum.
The abdominal wall is now drawn outward over the
costal arch with the left hand and then a long cut is
made through the peritoneum and the attachment of
the abdominal muscles to the margins of ribs from the
xiphoid process out to the eleventh rib. The anterior
attachments of the thoracic muscles to the sternum
are then divided by vertical incisions ; the left hand
grasps the layer of soft tissue, the fingers resting on
the external, the thumb on the internal surface, and as
the soft covering is pulled away from the thoracic cage,
the deep tissue is divided in long, sweeping incisions
that pass from below upward and outward. The soft
parts are dissected in this manner on both sides beyond
the costo-chondral junction.
If it is desired to examine the mammary glands
from the posterior surfaces or to expose the ribs, then
the soft parts may be dissected loose far beyond this
line. In the neck the platysma myoides is to be dis-
sected oflE in connection with the skin so as to expose
the greatest extent that one is allowed for cosmetic
reasons, of the larynx, the sterno-cleido-mastoid muscles
and the regions about the sterno-clavicular articulations.
It is now in order to carefully examine the soft
parts that have been exposed ; the amount and the con-
dition of subcutaneous adipose tissue can be accurately
ascertained; the thoracic and abdominal muscles are
also to be carefully scrutinized, and lastly the mammary
glands may, if occasion require it, be laid open and
examined from behind.
84 The Technique of Post-Mobtem Examination.
INSPECTION OF ABDOMEN.
A general inspection of the abdominal cavity should
be made at this time in order to avoid any possible
change in the position of the organs or mixture of
fluids that might ensue as a consequence of opening the
thoracic cavities. The color of the exposed organs
should also be determined immediately after opening
abdomen.
In medico- legal cases when the cause of death is
strongly suspected to exist within the abdomen it is
customary to examine the abdominal organs first; in
such instances the general order of procedure to be
described later on may be followed with such modifica-
tions as are necessary in consequence of the special
conditions in the individual case.
Inspection of the abdominal cavity include? thor-
ough investigation in regard to the position of the vari-
ous organs, the color and conditions of the peritoneal
surfaces, the contents of the cavity, abnormal adhe-
sions, etc.
The position of the liver and the stomach should
be carefully noted at this time, because of their ten-
dency to alter their position during the progress of
the autopsy. The various forms of hernia and other
intestinal malpositions are to be minutely looked for,
especially when symptoms of intestinal obstruction
were present during life. The omentum is to be raised
up and folded over the lower thoracic wall so that the
small intestine can be inspected from all points of view ;
for this purpose it must also be raised out of the pelvis
Examination of the Body. 85
as well as in order that abnormal contents may be
seen, as they have a tendency, if fluid, to accumulate
in the depressions of the peritoneal cavity such as the
pelvic and the regions about the kidneys.
The quantity, color, consistence and nature of the
abnormal contents should be determined at this time ; if
for any reason intestinal perforation may be thought to
exist, then the whole gastro-intestinal canal should be
minutely examined until it is definitely settled whether
perforation has occurred or not.
In women inspection of the pelvis takes note of the
size and shape of the uterus, the condition of the broad
ligaments and the ovaries.
The particular regions in the abdomen in which
old adhesions are most frequently encountered are the
pelvic cavity in women, the ilio-caecal region, where
they are usually connected with the vermiform appendix,
about the gall bladder and around the spleen.
In separating old or recent peritoneal adhesions
great care should be exercised not to exert such trac-
tion upon the perhaps distended and weakened intestine
as to produce rupture and extravasation of possibly
large quantities of fluid fecal matter.
Finally the position of the diaphragm is deter-
mined by inserting the fingers of the right hand first
under one and then under the other costal arch up to
its highest point (on the right side outside the falciform
ligament), and then by pressing the fingers against the
chest wall the exact height of the midriflE can be made
out with reference either to a rib or interspace. The
same point should be selected on each side, as, for j
86 The Technique of Post- Mortem Examination.
instance, the junction of the cartilages with the ribs,
in order that the comparison may be a legitimate one.
In this way information may be obtained with reference
to the condition of the thoracic cavities as regards
their degree of distension.
OPENING THE CHEST.
The costal cartilages are divided as near their
junction with the ribs as possible with a heavy knife
which is held parallel with the surface, so as to avoid
cutting the heart or the lungs ; the division commences
with the second rib and extends downward and outward
in a line with the costo-chondral insertion and by press-
ing on the back of the knife with the left hand the car-
tilages are readily and continuously cut across without
removing the knife except when calcification has taken
place, and then the ribs should be divided by means
of an ordinary saw just beyond the chondral insertion
(Fig. 22).
In cases of suspected pneumothorax a small pocket
should be made in the soft parts over an intercostal
space and this may be filled with water; on puncturing
the pleura the gas will bubble through the water.
The portion of the diaphragm between the lines
dividing the costal cartilages is now severed immedi-
ately underneath the ensiform cartilage and the false
ribs, and the sternum, lifted forcibly up, is rapidly sep-
arated from the tissues of the anterior mediastinum,
(great caution being used not to injure the subjacent
structures) , clear up to the sternoclavicular articulations.
Examination of the Body. 87
The stemo-clavicular joints are best disarticulated
in the following manner, because then the large vessels
are least liable to injury: Lift the sternum up and
draw it quite forcibly to the right with the left hand;
now cut the cartilage of the first rib from below up-
ward; incise the structures over the left stemo-clavicu-
lar joint from below upward and backward also, the
edge of the knife being directed up and backward; as
the articular surfaces become exposed, the remaining
ligaments are easily cut. By similar manipulation the
right joint is separated and the whole sternum with the
costal cartilages is placed to one side.
Too much force in lifting the breast bone up may
fracture the manubrium near its junction with the
middle piece.
Disarticulation of the clavicles by means of semi-
lunar incisions with a thin knife, the convexity being
directed inward, is liable to damage the large vessels
and lead to the confusing presence of blood in the
pleural cavities, unless made with great care and expert-
ness. By grasping the clavicle and moving it the exact
location of the sterno-clavicular joints can be determined.
INSPECTION OF THE CHEST CAVITIES.
After removal of the sternum the amount of dis-
tension and the general appearance of the lungs as to
color should be noted.
The natural tendency of healthy lungs to collapse
almost immediately after opening the chest may be
overcome in a variety of ways, as, for instance, by
fibrous pleuritic adhesions, by the filling of the alveoli
88 The Technique of Post-Mortem Examination.
with solid or fluid substances, by laryngeal and other
obstructions which prevent the escape of the air.
The pleural cavities are to be examined for abnormal
contents, the character and the amount of which are care-
fully noted. Pleuritic adhesions which either partly
or completely obliterate the cavities are also taken note
of at this time, but the separation of tough and quite
extensive adhesions must be postponed until the time
for the removal of the lungs.
The mediastinum is also to be examined in a gen-
eral way at this time ; the thymus gland should be looked
for because it may persist long after the usual time for
its complete disappearance. The condition of the great
vessels in the mediastinum must be ascertained as far as
that is possible by means of external palpation so that
the presence of aneurisms or other abnormal conditions
does not escape notice and become incised unawares on
removing the heart.
THE PERICARDIUM.
In order to open the pericardium a small incision
is made in the centre of the anterior surface, a small
fold being first pinched up in order to prevent injury
to the heart ; through this incision two fingers of the
left hand are introduced which lift the pericardium
away from the heart as the incision is prolonged first
downward to the left, then downward to the right, and
then upward as far as the point of reflection of the peri-
cardium upon the large vessels.
The escape of fluid through this incision must be
guarded against by removing the excess while the
Examination of the Body. 89
incision is still limited. The contents of the peri-
cardium are to be examined with reference to quantity
and to nature. The surface of the pericardial layers
which normally is smooth and shining, is also to be
inspected for minute as well as extensive changes, such
as inflammatory exudates, circumscribed thickenings
and opacities, fibrous adhesions, subpericardial ecchy-
moses in death from suffocation, etc.
Should the cavity be completely obliterated by
fibrous adhesions, then it will probably be best to
remove the pericardium and the heart together without
any attempt at separation, which is exceedingly liable
to result in rupture of the thin auricular and right ven-
tricular walls. It will consequently be best to make
the necessary incisions into the heart through the peri-
cardium and the heart- wall at the same time; in the
case of firm, circumscribed adhesions the adherent
parietal pericardium may be cut away from the rest of
the membrane.
THE HEART.
There are a number of methods of examination of
this important organ each of which may, if thoroughly
understood, yield very satisfactory results. The prin-
ciple involved in these various methods is quite the
same, namely: each step in the procedure must not in
any way interfere with the parts of the heart that may
remain to be examined.
The external examination of this organ can be
largely completed while it is still in situ and before any
incision is made into any of its compartments.
90 The Technique op Post-Mortem Examination.
The position of the organ in general, and of the
apex in particular, should be noted whenever there is
any change in this respect; it may be measured in its
greatest transverse diameter as well as from base to
apex; the form can readily be studied; normally the
apex is formed by the left ventricle alone and when the
right ventricle participates in its formation, an enlarge-
ment is present on the right side of the heart.
The consistency of the various portions depends on
the degree of muscular contraction and on the amount
and the condition of the contents; simple contraction
may completely obliterate the cavities while distending
fluid contents always yield to pressure.
It is very important in medico-legal acses to care-
fully examine into the condition of the coronary vessels
as they are observed with the heart in situ. The
coronary arteries and veins are readily distinguished
between on account of the difference in the thickness
of their walls and in their course; a marked distension
of the veins upon the anterior surface of the heart
points to obstruction to the outflow from the right
auricle and it is consequently usually observed in cases
of death from asphyxia; distension of the coronary veins
on the posterior surface alone is usually due to hypo-
stasis. Arterio-sclerotic coronaries can often be recog-
nized on account of their rigidity and the streaks of
whitish or greyish-yellow color which mark their sinu-
ous course.
It is quite customary to open the various compart-
ments of the heart while it is still in situ in order to
determine the amount and the condition of the blood
Examination of the Body. 91
contained in each. Inasmuch as the fluid blood does not
remain stationary after death either before or after
opening the heart, as the clotted blood remains until
after the removal of the heart, and as the condition of
the cavities as regards the amount of blood contained
in them can be quite as accurately determined by
external examination, it becomes somewhat diflScult to
understand the necessity of always opening the heart
before its removal. However, the incisions for this
purpose can be made in such fixed locations as to serve
as the commencement of those employed in the more
complete examination after removal, and in certain
medico-legal cases of some of the various forms of
asphyxia or in which the blood is to be retained for
analysis, it may be well to estimate as closely as possi-
ble the amount of the blood in each cardiac cavity.
Place the left hand under the heart, draw it down-
ward and to the left so as to bring the points where the
superior and inferior vena cava enter the auricle plainly
into view; make an incision into its cavity between
these two points down to a little above the transverse
furrow.
The right ventricle is then opened along its
right border by an incision that commences immedi-
ately below the circular furrow and runs downward in
line with the incision into the auricle, stopping short
of the apex in order to avoid the interventricular sep-
tum ; now place the knife to one side and remove the
fluid blood and the loose clots that may be present in
the two cavities of the right heart; the size of the tri-
cuspid orifice may be estimated at the same time by
92 The Technique of Post-Mortem Examination.
inserting the fingers of the right hand through from
auricle into ventricle ; ordinarily the orifice admits four
fingers.
In order to incise the cavities on the left side the
heart is grasped so that the fingers of the left hand lie
upon the anterior surface and the thumb on the poste-
rior, the apex resting in the hollow of the palm ; the
organ is then drawn to the right at the same time as
pressui'e with the thumb near the septum makes the
left ventricle bulge out somewhat prominently. Then
make an incision from the left superior pulmonary vein
through the auricular wall nearly down to the trans-
verse furrow ; then the cavity of the left ventricle is
opened at once by an incision which commences below
the transverse furrow and extends along the left margin
down to the apex.
The knife is again placed to one side and the con-
tents removed from the cavities now opened; the
diameter of the mitral orifice may be estimated in the
same way as the tricuspid; ordinarily it admits two or
three finger tips, depending, of course, somewhat on the
size of the fingers. Firm rigor mortis of the ventricle
may contract the orifice somewhat and then the rigidity
must be carefully overcome by spreading the fingers
apart.
At this time no effort should be made at palpation
of the free valve margins on account of the danger of
removing vegetations and thrombotic masses. This
method of estimating the diameters of the orifices is
not nearly so satisfactory nor precise as the use of
Examination of the Body. H3
graduated cones and, i£ they are at hand, then it is
not advisable to insert the fingei's as detailed.
In making the four incisions refeired to, the large
coronary branches should he avoided as much as possi-
ble, and in the distiicts cut across at this time but few
of these vessels occur as a rule.
In all cases of sudden death it is well to open
the pulmonary artery in situ in order to determine the
absence or presence of emboli,
Tlie heart ia now removed iu the following way :
insert the left thumb into the right and the forefinger
into the left ventricle, draw the heart directly upward
and cut successively the vessels that enter and leave it
as near the pericardium as possible (Fig. 23).
94 The Technique of Post-Mortem Examination.
In the routine examination the next step consists
in testing the competency of the semilunar valves with
water; for this purpose all coagula are extracted from
the orifices and while the heart is held by the auricles
so that the plane of the orifice is horizontal — in this
way distortion is avoided and the valves are not given
unnatural support from below — a column of water is
poured into the aorta or pulmonary artery as the case
may be ; ♦ these vessels should be trimmed down so that
the behavior of the semilunar valves can be readily ob-
served through the column of water poured in to test their
competency; in case any of the large coronary branches
have been cut across enough water may trickle away to
throw doubt upon the integrity of the valves unless
they are seen from above to meet exactly andperfectly.
*"The substitution of air for water will be found a great
improvement on the water method, as it may be utilized for all the
valves, and can be made to display the action of the cusps in
motion. The following is the manner of adapting it to the various
orifices.
*' An incision is first made into the left auricle and any post-
mortem clots are carefully removed from the left chambers through
it. Another incision large enough to admit the nozzle of a half -inch
tube is made into the ventricle near its apex and in the line of that
required for laying it fully open. The tube is joined to a bellows
and air is driven intermittently into the ventricle by means of it, the
aorta having been meanwhile closed. The valve will be seen to open
and close, according as the air is aspirated or driven out of the bel-
lows. A like procedure is adopted for the demonstration of the tri-
cuspid. To test the aortic valve, the incision before described as
necessary to open the left ventricle is continued up as close to the
valve as possible without injuring it. The tube is tied into the
aorta, and the action of the valve is watched from below. The
same method is used to test the competency of the pulmonary
artery valve." — (Hamilton).
Examination of the Body. 95
The heart can now be opened completely by pass-
ing the blunt end of a properly constructed enterotonie
(Fig. 24) into the right ventricle above the attachment
of the papillary muscle to the anterior wall and then
cutting through the wall as far to the left as possible,
stopping below the pulmonary ring, if its circumference
is to be measured with a graduated cone, otherwise the
incision is continued into the pulmonary artery (Fig. 25).
The reason that the papillary muscle attached to
the anterior wall of the right ventricle should not be
cut is mainly this, that after the muscle has been
FlS* !iB4.— Enterotome with smooth, blunt projection.
severed the tricuspid orifice dilates somewhat on account
of relaxation of the valvular structures and hence any
measurements after cutting across the muscular mass
referred to would not be entirely reliable.
If the scissors are held as far as possible to the left
the division will pass between two of two pulmonary
valve segments without injury to either (Fig. 26).
Open the left ventricle in somewhat the same
manner by passing the enterotome upward into the ven-
tricle from the incision already made, then cut along
the interventricular septum, then between the pulmon-
9S The Technique of Fost-Mobtek Exahihatiox.
ary artery and the auricle, throagh the aorta ; one of
the segmeDts of the aortic valves is anavoidably cat in
two by this incision (Fig. 27).
If the graduated cones are used (Fig. 28), then
these incisions into the ventricles are only partially
completed, the orifices being left intact All the orifices,
the aortic, mitral, pulmonary and tricuspid, are first
measured by pushing the cone carefully through the
opening in the direction of the blood current until it is
Fls. K8.-OTaila
felt to be arrested; after this the incisions just de-
scribed may be continued through the orifices so that
the ventricles are laid wide open.
The auricles may be opened still more than waa
done while the heart remained in situ by prolonging
those incisions out through veins on each side. In
this way a good view may be obtained of the auricular
100 The Technique of Post-Mobtem Examination.
aspect of the mitral and tricuspid valves. Finally, if it
is desirable, the original incisions into the auricles
and the ventricles on each side may be united by a eut
which divides the mitral and tricuspid rings.
In the ordinary clinical case it may not be con-
sidered necessary to open the heart in situ and it is re-
moved after a careful external examination by cutting
oflP the vessels as far away from the organ as possible,
as the left hand lifts it upward and out of the chest.
It should be placed immediately on a plate so that the
blood does not drip upon the body and its surroundings.
The heart cavities can be opened after a still more com-
plete external examination.
The auricles may be laid widely open by incis-
ions, which in the right runs fi'om the mouth of the
superior to that of the inferior vena cava, in the left
between the orifices of the pulmonary veins; all blood
clots can now be cleared out from these compartments.
Now place the heart on a smooth surface with
the posterior aspect downward, and the apex toward
the examiner, make a small opening into each ven-
tricle near the apex with the enterotome; prolong this
incision upward along the septum on both sides and
also along the right and left margins of each respective
ventricle, but stop short of the various cardiac orifices;
the ventricles are now emptied of blood clots, the com-
petency of the semilunar valves are tested with water in
the same way as already described and the diameter of
the orifices measured with the graduated cone.
After this the ventricles may be incised completely
by carrying the incision (Fig. 26) into the right out
Examination of the Body. 101
through the pulmonary artery; and the one in the left
out through the aorta; finally the auriculo- ventricular
valve rings may be divided by an incision uniting the
cuts into ventricle and auricle on each side.
All these incisions can be made with an entero-
tome, the blunt end of which must be perfectly smooth
and not hooked, otherwise it becomes caught in the
papillary muscles and chordsB tendinese of the ventricles.
With a little practice and caution the heart can be
readily laid open with a suitable knife also, in the
manner above indicated.
It will be observed that the heart removed without
opening any of its cavities should present very nearly,
if not exactly, the same appearance as to incisions,
while the same observations have been taken, as when
the partial openings made while the heart was still in
situ, were completed after its removal from the body.
We are now in position to make a detailed exami-
nation of all parts of the heart and for the sake of com-
pleteness this should follow some fairly definite order.
Commencing with the aortic valves the valvular and the
mural endocardium may be studied first in the left and
then in the right side of the heart, careful notes being
made of whatever pathologic conditions are found.
Then the size of the ventricles both as to the wall thick-
ness and the depth of the cavities must be measured;
the depth is measured from the base of the semilunars
down to the apex of the ventricles. The auricles can
also be measured as to the thickness of their walls and
their size may be estimated in a general way. While
these measurements give a fairly accurate idea as to
102 The Technique of Post-Mobtem Examination.
condition of the heart with reference to atrophy or hy-
pertrophy, yet the weight of the organ affords the most
accurate indication of absolute increase or diminution.
The shape of the ventricles and the condition of
the papillary muscles must be noted in hypertrophied
hearts.
The myocardium should be carefully examined
as regards the color, the consistence and the special
morbid conditions, but before any new incisions are
made through the muscular tissue the coronary arteries
must be subjected to a careful examination which begins
with and includes the commencement of the aorta
because the coronary orifices may be seriously involved
in the sclerotic changes so often found immediately
above the aortic valves. In all cases of sudden death
from obscure causes the condition of the coronary ves-
sels must be watchfully studied for the changes em-
braced under the term arterio-sclerosis and their con-
sequences; for this purpose the coronaries are incised
with a small, sharp scissors from their beginning upon
the aorta out to the minutest ramifications that can be
laid open ; in the case of doubtful instances of coronary
disease and secondary myocardial changes microscopic
examination may show astonishingly extensive lesions.
Variations in the origin of the coronary arteries
are common; they may have a common orifice, they
may both arise from the same sinus of Valsalva, or, a
third coronary may arise from the pulmonary.
In order to obtain extensive cut surfaces of the
myocardium further incisions may be made into it,
either vertical or paralel to the surface of the heart;
Examination of the Body. 103
thus the wall of the left ventricle can usually be nicely
divided into an outer and an inner half which present
comprehensive views of the cut surface; the interven-
tricular septum may be divided by a vertical incision.
As the various steps in the routine examination of
the heart are essentially the same whether the organ is
removed before any incisions are made into its compart-
ments or not, the following enumeration may be in
order:
1. External examination.
2. Preliminary incision into auricles and ven-
tricles and removal of contents.
3. Water test of semilunar valves.
4. Measure orifices with graduated cones or
fingers.
5. Open ventricles and auricles fully.
6. Examine endocardium systematically.
7. Measure thickness and depth of ventricles.
8. Weigh the heart.
9. Examine the commencement of the aorta and
the coronary arteries.
10. Expose the myocardium by free incisions.
The general principles that form the foundation of
this routine method of examination of the heart may
be summarily stated as follows:
1. The preliminary incisions are necessary in
order to empty the cardiac cavities and to make it
possible to apply the water test to the semilunar valves.
2. The preliminary incisions must avoid all valv-
ular orifices because their size must be determined with
the cone or the fingers ; they must also avoid the large
104 The Technique of Post-Mobtbm Examination.
coronary branches in order that the water tdSt of the
aortic semilunars may be as positive and decisive a&
possible.
3. The preliminary incisions are therefore to be
made in certain fixed locations, not alone for the above
reasons but also in order that they may serve as the
commencement of the incisions that lay the cavities
widely open. Consequently the left auricle is incised
from the mouth of one pulmonary vein to the other,
the left ventricle along the left border to the apex and
then upward along the septum; the right auricle is
incised from one vena cava to the other, and the right
ventricle along its right border and then upward to the
right of the septum, avoiding the papillary muscle upon
the anterior wall.
4. After having tested the semilunar valves and
measured the orifices, the heart cavities are completely
opened by uniting the incisions into the auricles and
ventricles on each side and by continuing the incisions
near the septum out through the pulmonary artery and
the aorta (Fig. 26).
THE PLEURA AND THE LUNGS.
Adhesions between the lungs and the chest wall
as well as the pericardium must be loosened first on
one side and then on the other. Should it be found
that the adhesions are so firm that there is liability of
tearing the pulmonary parenchyma in order to separate
them, then the parietal pleura must be removed at the
same time as the lung. For this purpose the costal
pleura is incised parallel with the costo-chondral junc-
Examination of the Body. 105
tion, and then the index-finger of the right hand worka
itself in between the pleura and the chest wall in an
intercostal space; by traction and by a side-to-side
movement the whole hand may be gradually intro-
duced, which then completes the separation: at the
apex it may be necessary to cut across with the knife
the dense cicatricial masses sometimes encountered.
In order to separate the costal pleura on the right
side in this manner it is necessary for the operator to
stand on the left side of the body for the time being ; to
protect the back of the hand against scratches from the
cut cartilages it is well to fold the soft covering of the
chest wall over the cartilages.
Detachment of the parietal pleura in this way in
the case of old empyemas often yields instructive spe-
cimens, as the abscess can then be removed in connec-
tion with the lung.
Inseparable adhesions between the lung and the
diaphragm or the pericardium will necessitate the
adherent portions of these structures being cut loose
and removed with the lung.
After completely separating all adhesions that
may exist, the lungs are removed by cutting across
the bronchi and the vessels at the root of each, being
careful not to wound the aorta or the esophagus.
After the removal of the lungs the pulmonary
pleura is again subjected to a careful and systematic
examination which has in view the detection of minute
as well as more extensive lesions of various kinds^
such as pleuritis, tuberculosis, circumscribed necrosis,
changes in the lymphatic vessels, etc.
106 The Technique of Post-Mortem Examination.
Then the various lobes of the lungs are studied
with particular reference to deviations in size, weight,
color, degree of distension with air, and consistency.
Each lung should be weighed separately.
Various conditions of the pulmonary, parenchyma
may be recognized externally by their color, as, for
instance, the bluish-red areas of atelectasis in broncho-
pneumonia.
By palpation considerable definite information
may be gained as to the amount of air present in the
lungs; the soft crepitation of the normal lung sub-
stance is absent in the firm, solid, distended lung of
lobar pneumonia as well as in the condensed lung of
atelectasis.
Inflation of the lung by means of a blow-pipe
inserted in a bronchus will show whether distension is
possible or not in certain lungs; inflation will also
demonstrate well the characteristic appearance of dis-
tension in emphysematous lung tissue as well as the
opening in the pleura in pneumo-thorax. Palpation
will also indicate the presence of cavities over which
fluctuation may be felt.
In order to incise the lungs each must be placed
^*on its diaphragmatic surface, the root being so grasped
in the left hand that the primary bronchus lies in the
fork between the thumb and forefinger;" an incision is
then made from the apex to the base along the convex
border so as to expose the largest possible extent of out
surface ; this incision should pass through the center of
the root so that the large vessels and bronchi may be
laid open at the same time.
Examination of the Body. 107
Or the lung may be placed with the hilus and base
against the table, and while it is supported in this posi-
tion by means of the left hand, the fingers of which are
spread out upon the surface of both upper and lower
lobes, an incision is made clear through to the root
extending from top to bottom. This incision should
be made with one stroke of a long, sharp knife, and it
cannot be regarded as correctly made if the bronchi that
go to the upper and lower lobes are cut off from the
main bronchus (Fig. 29).
The middle right lobe should be laid open with an
independent incision through its greatest diameter.
These lung incisions are readily made when the
organ remains distended on account of abnormal sub-
stances in the alveoli, as in lobar pneumonia, but it is
rather difficult to make a satisfactory cut into collapsed,
spongy, healthy lung parenchyma unless a very sharp
knife is used.
Gentle compression of the lung will demonstrate
the condition of the parenchyma in the various parts
as regards the presence of air, of edematous fluid, of
blood, etc. The color of the cut surface should be
noted. In the various pneumonias casts may be scraped
from the surface and in pulmonary tuberculosis the
generous display of cut surface will aid one much in
locating the lesions and in distinguishing between the
different varieties. Absolutely solid pieces of lung
tissue sink in water.
There are a number of circumscribed lesions, how-
ever, that might escape detection if only one large incis-
ion were made; consequently the bronchi must be
Examination of the Body. 109
opened by means of small probe-pointed scissors out
into their smallest branches, as much of the lung tissue
being included between the blades as possible; fre-
quently a grooved director inserted into a bronchus
will be of aid in incising the overlying tissue, which
should always be done with' probe-pointed, sharp scis-
sors, boring and violent twisting being avoided. In
this way bronchiectasia, vomicae, peribronchitic areas,
caseous and calcareous foci, slaty areas, and a number
of other small, local lesions may be discovered at the
same time that the condition of the bronchial mucous
membrane is ascertained.
The pulmonary vessels are also to be laid open with
probe-pointed scissors so as to expose the intima, and
demonstrate the absence and presence of thrombosis
or embolism.
In cases of death following extensive fractures or
crushing and laceration of the soft tissues the lung
parenchyma should be examined microscopically for
capillary fat embolism.
The bronchial glands are divided with a knife, and
in case they are found in advanced tuberculosis the con-
dition of the adjacent vascular and bronchial wall must
be carefully examined for extension of the process by
continuity and contiguity of tissue, because thus they
might become the point of origin of pulmonary or acute
general miliary tuberculosis.
Now that the lungs have been removed there is
abundant opportunity to examine the costal pleura and
the ribs, especially their posterior portions.
110 The Technique of Post-Mobtem Examination.
THE NECK AND ITS OBGANS.
The larynx and pharynx must be carefully exam-
ined in all cases of sudden death from unknown causes.
In medico-legal cases an exceedingly painstaking
and thorough examination of all the structures in the
neck may become necessary, especially when death is
suspected to have resulted from drowning or strangula-
tion or when suspicious marks are observed during the
external inspection. This dissection may be done
either before or after the removal of the sternum and
the lungs, but preferably afterward.
In purely clinical cases the extent of the examina-
tion of the neck and the mouth will vary considerably,
depending largely on the peculiarities of the individual
cases and the special object in view at the time.
The larynx and trachea may be opened from the
front and their contents and mucous membrane in-
spected; from the larynx the finger maybe passed into
the pharynx and any large foreign or loose bodies can
then be readily felt.
When important changes or injuries are suspected,
or when a thorough examination is necessary for any
purpose whatsoever, then the trachea, larynx and other
organs in the neck as well as those in the mouth should
be removed together and examined afterward. In that
case it is undoubtedly best to examine the great vessels
and the nerve trunks first because of the disturbance
and probable injury during the removal of the larynx
and other organs.
First the skin is to be carefully dissected loose
on each side, so that the jdp is visible out ia
Examination of the Body. Ill
the angles, the median incision extending to the sym-
physis menti; on the neck the sterno-cleido-mastoid
muscles are exposed. The large vessels can now be
isolated throughout their entire extent, they can be laid
open in order to determine the condition of the intima
which may be ruptured in cases of hanging and strangu-
lation by other methods. The internal jugular vein
may be the seat of thrombo-phlebitis, the primary cause
of which might be ear suppuration.
At the same time the deep muscles and other struc-
tures can be examined for bruises and blood extravasa-
tion. At this time the nerves may be dissected out also.
It will be recollected that the vagus usually lies between
and behind the carotid artery and the jugular vein.
In order to isolate the sympathetic the carotid is
drawn outward with a hook and the areolar tissue
behind it is separated; the nerve lies upon the muscles
covering the anterior surface of the cervical vertebrae
and it can be followed upward and downward until all
the ganglia have been found. The superior cervical
sympathetic ganglion lies upon or near the transverse
processes of the second and third vertebrae behind the
carotid and the vagus; the middle ganglion, which is
often missing, is usually placed opposite the fifth cervi-
cal vertebra. The inferior ganglion rests upon the head
of the first rib or the transverse process of the seventh
cervical vertebra, covered by the subclavian artery.
The vertebral artery may be exposed by removing
with bone forceps the portions of the transverse pro-
cesses, outside of the foramina they contain, of the six
112 The Technique of Post-Mobtem Exaionation.
tipper cervical vertebrse; the course of the vessel as it
ascends through the foramina is then readily followed.
After completing as much of the dissection as
may be necessary at this time the organs of the neck
and the mouth may be removed in the following man-
ner: pass a knife into the mouth from below at the
right or left angle of the jaw along the inner surface of
the bone; cut around to the opposite angle in close
apposition to the bone; at the chin some care must be
used so as to prevent piercing of the tongue tip.
The fingers of the left hand can now be introduced
into the mouth and the tongue can be pulled downward
at the same time as the knife divides the attachments of
the soft to the hard palate, and the posterior pharyngeal
wall coming forward on each side so as to include the
tonsils. It is perhaps best to divide the posterior
pharyngeal wall below Luschka's tonsil because in the
effort to go above it this lymphoid mass, if large, may
become damaged. Downward traction on the tongue
will enable one to separate the retro-pharyngeal connec-
tive tissue by means of short cuts; the connections
between the esophagus and the spine and deep cervi-
cal muscles yield very readily.
At the root of the neck the vessels going to the
upper extremities are cut across on either side in a
direction backward and outward, the left hand carrying
the organs of the neck from right to left and back to
the opposite side as occasion demands.
The separation of the gullet and the aorta from the
vertebral column is easily accomplished by means of
traction and the use of the knife; these structures may
Examination of the Body. 113
be cut across above the diaphragm or the stomach may be
removed in connection with the esophagus if so desired,
as might be the instance in cases of poisoning or of
malignant growths. In other cases the esophagus and
the bronchi may be divided above the arch of the aorta
and this vessel can then be removed in toto later on in
the course of the examination.
The organs of the neck are to be placed so that the
tip of the tongue points toward the pathologist, the
esophagus lying uppermost.
The dorsum, tip and edges of the tongue are to be
inspected, after which a number of transverse incisions
may be made. Then the soft palate is divided to one
side of the uvula, the pharyngeal mucous membrane is
inspected while the tonsils may be incised if necessary.
The esophagus is then to be laid open by means of
the enterotome along its left border and the general and
special morbid conditions of its wall and lining mem-
brane ascertained (Fig. 30).
The next step is the inspection of the larynx from
above; particular attention is to be directed to the
mucous membrane of the ary-epiglottic folds and the
form of the glottis. Edema of the glottis may disap-
pear almost completely after death, so that the mucous
membrane may lie in folds and wrinkles instead of
being smooth; this wrinkling is a sure sign of ante-
mortem edema which only occasionally may remain
quite marked after death.
The epiglottis is normally but very little curved
from side to side; in all instances of fatal suffocation it
assumes the suffocative position, by which is meant a
8
114 The Tbchsiqve or Post-Mobtem Examihation.
more or less marked approximation of ite edges as com-
pared with their aormal position.
Small foreif^ bodies are not to be overlooked.
The color and the degree of congestion of the mucosa
Bre also to be carefully noted.
Fl«. 80 — Tha orgMia of Uie hbuIi.
The soft palata hat been dlrlded to one ilde of th« nTulA And the eaophAgiiB
Mlimg ODB border.
The larynx and the trachea are to be incised poe-
teriorly along the middle line because here the carti-
laginous rings are incomplete; as this incision is made
the cut esophageal margin is drawn to one side so as
to avoid subdividing the esophagus; by means of the
fingers the laryngeal walJ can be spread apart so that
Examination op the Body. 115
full view is obtained of tliu interior oE tlie laryns which
can then (Fig. 30) be thoroughly examined, bearing in
mind what has just been said with reference to the epi-
glottis and to foreign bodies.
On account of the extreme delicacy of the lining
epithelium of the laryns great care must be exercised
v^
^H
r^
IWM
not to rub or scrape the mucoua membrane over the
districts that are selected for microscopic study.
The thyroid gtand can be separated fi'om its con-
nections, weighed, and incised, and at the same time
the form of the trachea can be noted.
The submaxillary glands, the cervical lymphatic
glands, the deep muscles of the neck, and the upper
1 16 The Technique of Post-Mobtem Examdultios.
part of the vertebral column can be readily examined in
varioijM wayH after the removal of the organs of the
f j<9ck, and any Hpecial dissection may perhaps be carried
on uiont readily at this time.
If tho a^>rta was removed with the esophagus, then
it in iff 1h) incised along its posterior walL
KKMOVAL OF ORGANS OF NECK AND CHEST
IN TOTO.
In many instances of interesting intra-thoracic
Um'uttm ii may seom advisable to remove the organs
of iho C/hoHi and the neck together in order that the
n?lationM of the various structures may be better pre-
H4»rv<5d. Among the conditions that indicate such pro-
cAulur*^ may bo rnontioned aneurisms, tumors, congenita
ti<?art h'HionM or malformations, and many other infre-
t\m*.tii hUil otUm during life obscure diseases.
Tlio \umri in to be opened in situ as usual; the
lun^H nro to ho fully loosened from all adhesions; the
or^anH in ilio n(ick are to be dissected free in the manner
ahovn (InHc.ribod, and then the large vessels on each side
at tli<i root of tlio neck are to be divided as they are put
on thn Htrnich ])y lifting each lung in turn toward the
oppoHJio Hido as far hb possible; as traction is made
upon ihi) l/irynx and esophagus with the left hand
tlio looHo Hhhuos between the spine and the aorta and
tlio (iHophagUH are readily divided by means of short
cuts wiili tlio knife, and as the organs fall out of the
tliorax, separation clear down to the diaphragm is easily
effected. The pericardial portion of the diaphragm
may be cut away and the gullet and aorta severed as
Examination op the Body. 117
they pass through this structure. Sometimes the stom-
ach and the abdominal aorta are removed in conjunction
with the contents of the chest.
The further dissection of the structures thus
removed in toto will have to be made in accordance
with the peculiarities of the special case.
In the case of aortic aneurisms and mediastinal
tumors it is often desirable to trace the course of such
nerves as the recurrent laryngeal in order to explain
interesting pressure symptoms observed during life; in
this instance the vagus should be isolated, before the
removal of the organs, down to and below the place of
origin of the recurrent laryngeal which can then be
more readily traced in the specimen after the removal
from the body. Similar plans may be followed with
reference to other structures which it may be difficult
to follow after their normal connections have been
severed to a certain extent.
THE ABDOMINAL CAVITY.
The examination of the abdominal cavity and of
its diversified contents often becomes a difficult prob-
lem, first on account of the close connection of the
various organs, and secondly on account of the dis-
turbance in their relations to each other in many of the
morbid conditions encountered. Chronic peritonitic
adhesions due to previous peritonitis, to carcinoma, or
to tuberculosis, extensive pus accumulations of various
kinds, complicated fecal fistulse, intestinal distension
due to gas and fluid, and many other conditions may
be mentioned, all of which may embarass to a certain
1 1 S The Techvique of Post-Mobtem EzAioxAnas.
tUif(rtt4i thf; examinatioD of the abdomen and modify the
tmnnl onlwr of procedure.
T\ui UHual Her|aence in ^hich the organs in the
tApthftuftn are removed is elaborated from the general
n»h% ^^that no organ shoald be remoTed^ the absence
of which would materially interfere with the subse-
qtjurii i5%ainination of other organs.^'
In ncnUi i>eriif>nitiB no organ should be remored
until th<) probable source of the inflammation has been
tittuU: out, or until it becomes clear that the mode of
or'n(iti ctiti not 1k3 made out until certain organs are
i'Antit'ituul ntU^r their removal.
'rh<5 following (loBcription of the technique of the
<fXiiniinHiic>n of the abdominal organs takes up the indi-
vidual MtructunjH in the order in which they are to be
iiikt'ti out and oxaininod as n general rule.
OMENTUM.
TIh? pohition of this structure is naturally first
U(tUu\. It may be found to one side, doubled up, in a
hernial M/ie, adlnirent or loose. In order to subject it
it} n Heruiinizing examination it may be cut away from
the tranHVi^rne colon and spread out on a smooth surface.
The onieniuni affords an excellent ready opportunity for
the rnicroHcopic} study of miliary tubercles, dissem-
inat45d carcinosis, and inflammatory changes, because
it is only recjuirod to excise a small piece from a por-
tion that is free from fat and spread it out in any ordin-
ary medium such as the physiologic salt solution.
Examination of the Body. 119
THE PEEITONEUM.
Considerable information has already been obtained
in regard to this membrane from the general inspection
of the abdominal cavity immediately after it was
opened.
The peritoneum should, however, at this time
again be scrutinized for evidences of recent and previ-
ous inflammation of diflferent forms ; certain regions, as
already stated, are prone to lesions of this kind, such
as the pelvis, about the vermiform appendix, about the
gall bladder and the bile ducts, and the spleen, and in
the routine examination these districts should always
receive especial attention.
Chronic adhesions in any part of the peritoneum
should always be inspected for tubercles and caseous
masses.
In case abnormal contents are present, the cavity
should now be thoroughly emptied and the total quan-
tity measured or estimated.
THE SPLEEN.
This should be grasped with the left hand and
drawn forward from its position behind the fundus of
the stomach. Any adhesions to the diaphragm must
be carefully separated so as to avoid tearing the splenic
structure. As it is drawn forward the gastro-splenic
omentum is brought into view and any gross changes
in the splenic vessels, any accessory spleens or unusual
conditions about the hilus can be readily noticed.
The organ is then removed by cutting across the
vessels near the hilus; it should be weighed and meas-
120 The Technique of Post-Mobtbm Examination.
ured; the outline and modifications of form, the color,
thickness, tenseness, and smoothness of the capsnle
should be noted; an incision is made from the convexity
to the hilus so as to divide it into equal halves, as many
additional incisions being made in the same direction
as may seem necessary. The color, the pulp, the folli-
cles, and the trabeculse can now be studied. The appli-
cation of tests for amyloid material should not be neg-
lected in suspicious cases.
THE ADEENALS AND THE KIDNEYS.
Each kidney and the corresponding adrenal are to
be exposed and removed together. It is customary to
begin with the left side.
The small intestine is to be brought out of the
abdomen and left hanging over to the right side. The
sigmoid meso-colon is divided near the intestine which
is placed on the stretch with the left hand; the perito-
neum to the outside of the descending colon and above
the splenic flexure is incised and these portions of the
large intestines are drawn over to the right, the retro-
peritoneal connective tissue yielding readily, and in
this way the left kidney can be quite fully uncovered.
By lifting up the fundus of the stomach and the
tail of the pancreas the left adrenal is also exposed.
The ureter can now be readily traced throughout
its entire extent and the vessels that enter the hilus of
the kidney can be isolated and accurately examined.
The kidney can be removed by separating it from
its connective tissue investment with the hand and draw-
ing it forcibly upward, the knife being used if necessary ;
Examination of the Body. 121
the vessels will yield to cautious traction or they may
be cut across. The ureter may be allowed to remain
connected with the pelvis in case this is thought best,
as in hydro-nephrosis and similar conditions, and the
kidney may be placed to the left of the body, to be
removed with the rest of the genito-urinary organs, or
the ureter may be cut off.
In order to remove the adrenal with the kidney it
must be loosened from its bed by means of small incis-
ions before the kidney is lifted out of the body; it is
very friable as a rule and must be handled with care
The right kidney and adrenal are removed similarly.
The small intestines are brought out of the abdomen to
the left. The peritoneum along the outer surface of
the cecum is incised and the meso-colon divided suffi-
ciently to permit the cecum, the ascending colon and
the hepatic flexure to be carried to the left, thus uncover-
ing the kidney. The liver may be allowed to fall into
the chest cavity by dividing the diaphragm and then
the right adrenal becomes readily accessible as it lies
in the shallow depression on the under surface of the
liver, from which it must be dissected loose, care being
used not to wound the closely adjacent vena cava. The
right ureter can be isolated down to its entrance into
the bladder.
In order to simply remove the kidneys an incision
may be made or an opening torn behind the upper por-
tions of the ascending and descending colon, through
which the hand may enter and loosen the kidneys which
are brought upward, the connections with the vessels
and the ureters being separated, but this method does
122 The Technique of Post-Mobtsm Examikation.
not afford any opportunity to examine the organs with
the adrenals, the vessels and the ureters all in situ.
In cases of acquired or congenital malposition of
the kidneys it may be necessary to deviate considerably
from the mode of procedure above detailed, because in
the instance of floating kidney the great lengthening of
the vessels and in the instance of the congenitally fixed
dislocations, with or without fusion, the alypical origin
and number of the vessels, may render a more exten-
sive dissection necessary than can be done with the
intestines still in the body. In fact, there can be no
objection whatsoever to removing the intestines in the
manner soon to be described before attempting any
examination of the kidneys or adrenals; such an order
of procedure could not but aid in the detection of
changes and abnormalities in the renal as well as other
vessels and in the ureters. In deference to old custom,
however, which undoubtedly originated from the fact
that in very many private and clinical cases no examina-
tion of the intestines is made, the method of securing a
reasonably thorough investigation of the renal vessels
and the ureters with the intestines in situ, has been
detailed.
The adrenals are to be detached from the kidneys,
weighed and measured. They are incised in the longest
diameter through their flattened surface.
The fatty capsule of the kidneys should be removed
before any incision is made; then they should be
weighed and measured, and the shape noted.
The next step is to divide the kidney into two
equal, longitudinal halves by an incision from the con-
EXAMISATION OF THE BoDY. 123
vex margin to the pelvia. The kidney is held firmly in
the left httud with the hilue in the angle between the
thumb and the fingers, the thumb being applied to one
surface and the fingers to the opposite aspect, and with
one stroke of the long knife the division into equal
halyes is made from one end to the other and from the
convex border as far as the hilua (Fig. 32). In this
way the largest possible cut surface is exposed.
To fully display the apices of the papillje it will be
necessary to cut open the pelvis and the calyces more
extensively with scissors.
In order to detach the fibrous capsule of the
kidney the cut margin is pinched up by the thumb and
finger and stripped oft from the surface. When the
capsule is thickened and adherent as a consequence of
chronic inflammation, then thin layers of cortical sub-
124 The Technique of Post-Mobtem Examinatiok.
stance are brought away with it The capsule most
not be stripped oflf from those parts intended for histo-
logic study.
After removal of the capsule the external surface
can be examined with reference to color, to smoothness
or granulation, depressions and furrows, cysts and
dilated vessels.
Next the attention is to be directed to the cut
surface of the kidney. The relative proportion of
the cortical and the medullary parts is important to
ascertain; in the normal kidney the thickness of the
cortex compared to the medullary portion is as 1 to 3 ;
the average width of the healthy cortex is 4 to 6 milli-
meters, but as the individual thickness may vary the
relative size of the cortex to that of the medulla is much
more important. This means the relative space occu-
pied by cortex and medulla, the measurement being
taken from the apex of a cone to the surface of the
kidney which must be vertically divided as nearly in
the median line as possible; the average of a few ren-
culi must always be taken, obliquely cut cones being
discarded. Any deviation in the normal proportional
measurement of 1 to 3 requires investigation as to
whether the cause of the disproportion lies in the cortex
or in the medulla, as the cortex may be atrophied or
increased in thickness, the medullary papillae may be
flattened or effaced.
The amount of blood in the kidney as a whole and
the distribution of the blood to its various divisions
must be noted.
\
Examination of the Body. 125
The cortical markings must be intently studied
because modifications in their normal appearance are
usually early present in the various inflammations and
degenerations.
The so-called cortical markings are due to the
alternating reddish and grayish striations of the renal
cortex formed by the medullary rays which are com-
posed of bundles of straight tubules of a clear, gray
color, conical in shape, the apex terminating near the
surface, and by the labyrinths which consist of the con-
voluted tubules, part of the loops of Henle, the glom-
eruli, and the vessels, the blood in which gives this
portion a varying shade of red. The medullary rays
are also sometimes referred to as the pyramids of
Ferrein and the labyrinths are often spoken of as the
regions of the convoluted tubules. The labyrinths show
the most frequent alterations in color, because parenchy-
matous changes appear first in them, as well as on
account of the dependence of the color upon the amount
of blood present in the vessels and the glomeruli (Fig.
33). In advanced difiPuse renal lesions the cortical
markings become more or less altered and obliterated,
the contrast between the medullary rays and labyrinths
disappearing.
It is also of interest to bear in mind that normally
the glomeruli are not found immediately underneath
the surface of the kidney; when these bodies are
superficial the kidney has atrophied.
While studying the cut kidney surface, note par-
ticularly the degree of distension and the condition of
126 The Technique of Post-Mobtxm Examinatioii.
the arteries as regards increased wall thickness as well
as other changes.
Local lesions of various kinds are to be looked for
in both cortex and medulla. The medullary region
must be closely examined for the mechanical effects of
excessive distension of the pelvis, for evidences of
ascending changes, secondary to lesions in the lower
urinary tract, and for the various forms of infarctions.
The mucous membrane of the pelvis and of its
calyces has been laid open to full view by means of
incisions with the scissors and the various anatomic
changes likely to occur can be looked for, such as
pyelitis, calculi, dilatation, and congenital anomalies.
The ureters, already examined externally before
removing the kidneys from the body, may be incised
with small scissors.
The examination of the kidneys may be recapitu-
lated, as follows:
1. The kidneys and the ureters are exposed so
fully while in situ that it can be determined whether
or not the kidneys are to be removed separately or in
conjunction with the other urinary and the genital
organs. Sinultaneously the vessels may be isolated.
2. Eemove the adrenals with the kidneys and
examine separately.
3. Weigh and measure the kidneys after separa-
ting the fatty capsules.
4. Longitudinal incision from convex border to
hilus, strip off fibrous capsule, and examine external
surface.
Examination of the Body. 127
5. Examine the section surface as regards relation
of cortex to medulla, cortical markings, shape of papil-
lae, etc.
6. Medulla, pelvis, ureter.
THE PELVIC VISCERA.
These organs, including the bladder, urethra, the
sexual apparatus and the rectum, should be removed
together.
In case it is necessary to accurately examine the
contents of the urinary bladder, this may be evacuated
with a metal catheter in order to avoid loss or admixture
with blood and other fluids ; in the case of absence of,
or obstruction to, the catheter the bladder may be
evacuated by means of a longitudinal incision in its
anterior surface.
The rectum must be separated from the descending
colon between a double ligature so as to avoid fecal
extravasation; the feces should always be pressed out
of the intestine at the place of application of the liga-
ture before this is tightened.
Then the bladder is to be drawn up away from the
pubes and the fingers of the right hand, their volar
surface toward the bladder, are insinuated behind the
symphysis, the loose retro-peritoneal connective tissue
is gradually separated from the inner pelvic wall so that
the hand can be passed all around the pelvic organs
and behind the rectum, great caution being used so as
not to in any way unduly compress the tissues. In
order to safely liberate the prostate completely, it is
best to cut the fascia about the anterior aspect of the
128 The Technique of Post-Mobtex Exaxdiatiov.
^laiid chme to it» attachment to the under snrfaoe of the
pubic arch. The pelvic viscera are now drawn firmly
tfiwanl the diaphragm while the right hand divides
witli tho knife tlie urethra, as far in front of the prostate
aH iHiHHible in men, the vagina at its middle in women,
an<i tlio n^ctuni an low down as possible. These viscera
aro now dragged out of the pelvis, the peritonenm is
<livid<id on all Hides; the tubes and ovaries must be
Hafitly in<;luded and the large vessels behind the peri-
toneum nuiHt not be cut into.
In riMi'i it iH necessary to include the urethra, the
t<mtl('.l()H, and tii<3 spermatic cords in men, or the exter-
nal gHniifilia and entire vagina in women, this order of
procM'duni liHH to be modified as follows: When it is
d<;Hirabl(^ to prcmorve the attachment of the urethra to
tli<i bhiddcr, the (rutaneous covering is loosened from
ilio \nm\H and thin organ is cut through more are less
Hubcruitirn'onHly as far forward as necessary. The pos-
terior ait/i<!lunentH to the pubes, the ligamentum sus-
penHoriiun and th(i lateral insertions of the corpora-
en v<*j'noHa urn cut HcroHH close to the l)one and the penis
ean We dniwn under the symphysis and removed with
the other organs as already detailed. Unless the sub-
pubic aitae>hnients are carefully severed the membran-
ous |K)rtion of the urethra may be torn across.
The testicles, after carefully noting their position,
if that bo abnormal, can be removed from the scrotum
by carefully enlarging the canals from the abdomen so
that the glands will slip out quite easily when pressed
ui)on from b(4ow ; the vasa def erentia may be isolated
Examination of the Body. 129
upon the sides of the pelvis down to the bladder,
before any extensive separation of the pelvic viscera is
attempted.
The female sexual organs together with the ure-
thra, the vagina, the external parts, the rectum inclu-
ding the anus may be dissected out by detaching the
pelvic viscera as before described; then the legs are
widely separated and a cutaneous incision is made
around the external genitalia, the perineum, and the
anus; the separation is continued underneath the
pubes and on the sides until the organs can be drawn
backward underneath the pubes, and raised up as the
separation is completed behind the lower end of the
rectum.
It will be readily seen that if the kidneys have
been loosened and the ureters isolated down to the
bladder before the pelvic organs are enucleated, then the
entire genito-urinary tract may be readily removed in
to to together with the rectum and anus; in many cases of
hydro- and pyo-nephrosis this procedure may be advis-
able and in extensive genito-urinary tuberculosis and
ascending vesico-uretero-pyelo-nephritis a comprehen-
sive view of the extent of the lesions is readily obtained
in this way.
After their removal the pelvic organs are to be
placed in their natural position, the rectum underneath
and examined as far as possible from above downward.
Urethra and Bladder, In the male the corpora
cavernosa are separated through the septum and an in-
cision is carried along the urethra into the bladder; in
the female the urethra may be divided in the same
9
130 The Technique of Post-Mortem Examikation.
way. In the male urethra strictures and false passciges
are especially to be looked for.
The bladder must be examined for hypertrophy,
tuberculosis, inflammations, traumatic lesions, and
tumors.
The Prostate. This is divided transversely in
front of the oblong eminence on the floor of the pros-
tatic urethra known as the caput gallinaginis or calli-
culus seminalis ; further transverse cuts may be made
if necessary. In this way the extent and location of
evident hypertrophy, local tuberculous and suppurative
foci and other lesions are exposed. It may be neces-
sary to examine carefully the veins about this gland for
evidences of thrombo-phlebitis.
The seminal vesicles lie between the rectum and
the bladder upon the posterior wall of the latter above
the prostate. In order to expose them the floor of the
recto-vesical fossa is to be turned upward and the ante-
rior wall of the rectum separated from the posterior
wall of the bladder. The two vesicles will then be seen
as rather long, flattened organs above the prostate and
they can be incised longitudinally. The vas deferens
on each side is easily seen at the same time and may
be incised with a very fine pair of scissors.
The Testicles and the Spermatic Cord. After
inspecting the exterior of the testicles and the epididy-
mis, noting the size and consistency as well, a longi-
tudinal incision is to be made through the testis, the
body of Highmore and the epididymis with such
separate cuts as may seem necessary to fully expose the
parenchyma. The testis must be firmly grasped while
Examination of the Body. 131
making this section, otherwise it may slip out from
between the fingers.
The Vulva, The external genital organs in the
female must be examined for lacerations, hematoma,
inflammation, and neoplasms.
In medico-legal cases of suspected abortion or rape
this examination becomes very important.
In the abortion cases punctures may be found in
the external genitals, produced by the unskillful use
of instruments, as well as the ordinary child-birth
lacerations. Superficial and deep, irregularly distributed
lacerations accompanied with swelling, discoloration and
perhaps purulent inflammation suggest rape; especially
would this be the case in children.
The Vagina. This canal may be incised on the
left side up to the cervix uteri; then it may be separated
from the anterior surface of the uterus, and in that way
its entire extent is laid open for inspection ; simultane-
ously the bladder may be dissected away from the
uterus. What has already been said with reference to
wounds and lacerations of the vulva applies to the
vagina also.
The Uterus, This is first measured externally in
its longest, broadest and thickest diameters, and varia-
tions in form as well as in position are carefully noted.
Retracting perimetritic adhesions are to be considered
with reference to their eflPect upon the position and
shape of the uterus.
Before opening the uterus it is well to study the
appearance of the external os which child-birth changes
from a smooth, transverse slit to an irregularly shaped
132 The Technique of Post-Mobtem Examination.
orifice, the margins of which show recent or cicatrized
tears. The uterus is incised along the middle of the
anterior wall from the cervix to the fundus; from the
upper end of and at right angles to this incision, two
shorter ones are to be made, outward to each uterine
opening of the Falloppian tubes. The thickness of the
walls is to be measured and the relative size of the
cervix compared to the body is to be estimated accu-
rately. The size of the uterine vessels and the thick-
ness of their walls are also to be noted. By means of
these observations it will usually be possible to deter-
mine whether any previous pregnancy has occurred
or not.
The color and consistency of the walls, the condi-
tion of the mucous membrane in regard to thickness
and color are necessary observations.
The menstrual and the puerperal uterus may
re(£uire differentiation, and for this purpose the examin-
ation of the ovaries in regard to the condition of the
corpus luteum will be of much service.
In order to study closely the condition of the ves-
sels, lymphatic as well as blood, in the puerperal uterus,
incisions are to be made into the walls, especially at
the placental attachment as well as elsewhere. Thrombo-
phlebitis or lymphangitis may commence in cervical
lacerations and these are consequently also to be incised
so that the nature of the vascular contents can be posi-
tively made out.
The Broad Ligamenis. The Falloppian tubes are
to be examined as to size and shape. The fimbrise are
to be spread open and an attempt may be made to press
Examination of the Body. 133
a little of the contents of the tubes out at the abdominal
end. The tubes are to be slit open along their entire
course. Dilatations, distortions due to adhesions, con-
genital twists and tortuosities demand careful investi-
gation.
The position and the size of the ovaries as well
as their shape are to be noted; the condition of the
external surface, the color and the consistency are all
points of importance. In order to expose section sur-
faces the ovaries are to be bisected by a longitudinal
incision through the broadest plane. The color, the
corpora fibrosa and lutea, possible cysts and abscesses,
etc., can now be examined.
The vessels in the parametrium must be carefully
examined. Thrombo-phlebitis and lymphangitis may
occur secondary to similar processes in the uterus or
vagina and may extend into the larger veins near by.
Marantic thrombi are frequent in the uterine plexus
and may give rise to sudden fatal pulmonary embolism ;
consequently these veins may have to be dissected out
and incised with great care. In connection with this it
is only necessary to mention that extra-uterine fetation
must be borne in mind in all instances of intra-peritoneal
hemorrhage in women, and that in the early stages it
may be quite impossible to discover the embryo. It is
also to be remembered that pus accumulations and tubal
hemorrhages may result from extra-uterine pregnancy.
The Rectum. This part of the intestinal canal
may be emptied of its fecal contents by means of a
gentle stream of water allowed to run through it, and
after that it is laid open with the enterotome along the
1:^4 The Technique of Post-Mobtik Exaiovation.
iniddlo of tlie posterior wall, the pelvic Tiscera now
lyint^ witli the bladder underneath. The mncons mem-
))raiie and tlie walls can now be examined with all neces-
sary iiiinuteiiess of detail
THE MESENTERY AND THE INTESTINES.
In tlie ordinary, routine post-mortem exaniination
tlie intestines up to the duodenum shonld now be
removed in order that as many as possible of the abdo-
minal ort^ans may have been taken out when it becomes
iiecesKary to examine into the patency of the bile pas-
sages, which involves opening the duodenum in sita
and n(M!(*sKfiri]v some extravasation of its contents. This
order ne(;essitates the examination of the mesentery at
this time.
The Mr soil cry. The thickness, form, and length
will be found to vary much. The mesenteric lymph
appurtitus is especially to be examined for enlargement
of the trlKiids and chanties in the lacteals. Usually the
il(;o-c(*,cjil chain is earliest and most extensively inyolyed,
be(;aiiHe the primary intestinal process (typhoid and
tiilxjHMdosis j is most marked nearest the valve. Throm-
bosis mfiy occur in the large mesenteric vessels second-
ary to stasis in the portal vein or to lesions in the intes-
tinal mucous membrane.
Jicntoral of Tnfrslines, After external inspection
of the bowels in situ, so as to have noted any unusual
dilatation, change in color, alterations in the peritoneal
coat, diverticula, etc., they may be removed in the follow-
ing manner: Grasp the lower end of the large intestine
which remains securely ligated from the time the rec-
EsAMISATION OF THE BoDY.
135
tam WR3 removed, make the intestine tense and then
sever all attachments close to the bowel. When the
small intestine is reached make the mesentery tense
with the left hand, divide it as near the intestine as pos-
sible without injury to the latter by means o£ an almost
continuous sawing motion of the knife, the edge o£
which is placed against the bowel (Fig. 34). In this
way all the mesentery is cut away and this allows
the intestinal coils to straighten out completely. As
the intestine is separated it may be allowed to fall
between the thighs of the body or into a pail at its
Bide, This detachment is continued as high up into
the ascending duodenum as possible when a double
ligatui'e is applied, between which the division is made.
The contents may be washed out by drawing the
upper extremity of the intestine over the faucet and
136 The Technique of Post-Mobtem Examikatiok.
letting a stream of water run through from one end to
the other. In special cases it may be advisable to
examine separately the contents of the different regions.
Both ends of such a portion may be ligated separately
so as to avoid loss of the contents or admixture with
other substances.
The further examination of the intestines may be
postponed until the very last for obvious reasons of
cleanliness ; this is, of course, entirely a matter of choice.
The small intestine is to be cut open along the mesen-
teric attachment, principally because Peyer's patches are
situated opposite thereto and they may be the seat of
very important lesions; this division is made by simply
drawing the intestine through a partially opened enter-
otome, the blunt end of which is passed into the lumen
of the bowel, and as this is continued the opened por-
tion may bo allowed to spread itself out over the fingers
of the left hand (Fig. 35).
The large intestine is incised in the same way
along one of the three longitudinal bands or tenia.
The intestine having been wholly opened, the con-
tents may, if necessary, be washed off by holding the
intestine under a stream of water. If this cannot be
done, then the bowel may be drawn between two of the
fingers of the left hand, and the portion cleansed in this
manner allowed to fall into a pail of clean water; this
process may be repeated as often as necessary.
In medico-legal cases it may be necessary to
examine the contents of different portions of the intes-
tinal tract separately in order to obtain information with
reference to the length of time that intervened between
I
Examination of i
E Body.
137
the taking of food and death, and perhaps in regard to
other points as well. In that ease the various parts
may be separately ligated as indicated above.
The examination of intestinal contents includes
observations upon their general characteristics, the quan-
tity, color, consistency, and odor; parasites, indigestible
food and various other abnormal ingredients must be
looked for.
Any of the above or of the following remarks in
regard to procedures that would result in obvious harm
to the mucous lining are not applicable to those parts
that are to be examined with the microscope.
Commencing with the upper end of the small in-
testine the entire mucosa and wall in general are now
subjected to a minute, systematic examination. In the
small intestine especial notice must be given the villi.
138 The Technique of Post-Mobtem Examination.
the valvnlae conniventes, the solitary and the agminate
lymphatic structures. The thickness of the wall mnst
be ascertained and the color of the mucosa noted; the
thickening may be general, in all the coats, or it may
involve only the mucosa and the submucosa when the
normal folds become larger and longer than normal;
folds may even form where they do not normally exist
as in the lower ileum. Normally single villi can hardly
be seen so as to be recognized with the naked eye; if
the villi are much enlarged they may be detected as
small, movable gray bodies.
The solitary and agminated follicles — Peyer's
patches — are normally just capable of recognition;
when easily and quickly seen they are enlarged. In
the ileum the transverse folds in the mucous membrane
suffer a more or less complete interruption at the site
of the Peyer's patches, whose location can consequently
readily be made out on this account even when not dis-
tinctly visible on account of morbid enlargement
The aggregations of lymphoid structures are most
extensive nearest the ileo-cecal valve, and the disease
processes peculiar to the glands are as a rule most
marked in this part of the intestine.
The vermiform appendage may be the seat of
important old and recent lesions; its mucous membrane
should be carefully inspected in all cases of peri-appen-
dical fibrous adhesions for scars and ulcers; it may
contain tubercular, typhoid, and catarrhal ulcers and
the appendage demands careful examination in all cases
of peritonitis.
Examination of the Body. 139
In the large intestine the longitadinal muscular
fibres are collected to form three flat bands which are
about one-half shorter than the rest of the intestine,
and thus "serve to produce the sacculi which are char-
acteristic of the cecum and the colon." It is upon the
projecting ridges thus formed that diphtheritic and
other processes first appear. In the flexures the sac-
culi may be dilated and filled with hard fecal masses.
THE COMMON BILE DUCT AND THE PORTAL
VEIN.
Before removing the stomach, the duodenum or
the liver, the common bile duct, the portal vein and the
hepatic artery must be examined as completely as possi-
ble while they are in situ, because the removal of those
organs destroys the normal connections and relations.
After the external examination, the patency of the
biliary passages may be tested in the following manner:
The liver lies in the thorax, the gall bladder point-
ing upward. A small incision is made in the anterior
wall of the second or transverse portion of the duode-
num. The common bile duct and the pancreatic duct
open separately or jointly upon the inner wall of the
transverse part of the duodenum, a little below its
middle, i. e,, about 9 ctm. below the pylorus; when
the duodenum is stretched transversely the papilla will
be seen just below the middle of the head of the pan-
creas. In order to determine whether the common bile
duct is pervious, especially in the duodenal portion, the
duct itself only is compressed between the fingers toward
the papilla which is closely watched to see if the bile
140 The Technique of Post-Mobtem Examination.
is forced out. In catarrhal jaundice the occluding
plug of desquamated epithelium may be minute and
liable to be forced out unnoticed. Afterwards the gall
bladder may be pressed upon in order to determine the
condition of the whole length of the duct as to permea-
bility.
The duct can now be probed from below and
incised by means of scissors; in the case of extensile
lesions the probing may be attempted from above
through the hepatic duct. Simultaneous probing of the
pancreatic duct may be undertaken.
The size of the duct is normally that of a goose-
quill. The mucous membrane is normally colored
with bile and if any obstruction has existed the portion
below will be found free from biliary discoloration.
Ulcers, perforations, strictures, cicatricial occlusions
and various forms of inflammation may be found.
Tumors and cicatricial contraction often render this
examination troublesome.
The portal vein lies in the folds of the lesser
omentum behind the common duct. After careful
investigation of its surroundings and the exterior for
evidences of chronic and acute inflammation, the vein
may be slit open through its entire extent and its
contents and structure can be examined. Malignant
growths may perforate the walls of this vein; it may
be the seat of a simple thrombosis due to various reas-
ons and a portal thrombo-phlebitis may occur secondarily
to the numerous forms of infectious lesions situated in
the extensive territory drained by its branches.
The hepatic artery can also be slit open.
Examination of the Body. 141
THE LIVER AND THE GALL BLADDER.
It is of course a matter of choice whether the liver
and the gall bladder are removed before or after the
stomach and the duodenum.
If the latter are to be incised fully in situ it would
perhaps be best on account of reasons of cleanliness to
remove the liver first.
If there are no contraindications in the shape of
adhesions with neighboring organs, fistulse, etc., then
the liver may be taken out in the following manner:
All the attachments of the right lobe are severed in
the order in which they are met with as the liver is
lifted up, such as the structures in the hepato-duodenal
ligament; the left lobe is drawn over to the right and
the tense attachments about it are divided, and lastly
the broad ligament is severed. In case firm adhesions
exist between the liver and the diaphragm, then the
latter may be removed at the same time.
In cases of cirrhosis the ligamentum teres or round
ligament may be examined for a persistent umbilical,
or a para-umbilical, vein.
The liver is to be placed upon its anterior surface
and the exterior and interior of the gall-bladder exam-
ined. After having noted any changes in the general
appearance and in the serous coat the bladder may be
opened by a longitudinal incision and the contents
examined; the cystic duct should be slit open, in this
way the presence of cholelithiasis and its consequences
as well as other changes are readily seen. The bile
ducts and the larger branches of the portal vein may
112 The Ibchmique of Post-Mobtbu Examination.
be still further slit up and the examination already
made while they were in situ completed, as it were.
The portal lymphatic glands are aUo to be investigated
at this time.
The inferior vena cava, a portion of which is
usually removed with the liver, may be laid open.
The liver is now placed upon its inferior surface
and its dimensions. taken; the transverse diameter of the
whole organ and of the right and the left lobes separ-
ately, the antero- posterior diameter of these two lobes and
also their thickness. Then the liver may be weighed.
Yariations in the usual shape, the general color,
and the consistency and the condition of the capsule
are now noted.
In order to expose the interior, long incisions pass-
ing transversely througli the right and the left lobes at
the same time may be made. The number of these
s may be multiplied at pleasure, but they should
larly parallel as possible (Fig- 36).
Examination of the Body. 143
The quantity of blood present in the hepatic vessels
may be estimated by noting the amount that flows out
upon the cut surfaces and that can be squeezed out of
the parenchyma. The consistency and the smoothness
or roughness of the cut surfaces are determined by
palpation.
In order to distinguish between the two venous
systems in the liver it is simply necessary to recollect
that the portal branches are surrounded by the connec-
tive tissue of Glisson's capsule and accompanied by the
bile ducts and the branches of the hepatic artery,
whereas the hepatic veins occur singly, are very thin,
and in direct apposition to the parenchyma in conse-
quence of which fact they remain widely patent when
cut across.
The description of the surface of a liver section is
quite generally based upon the appearance presented
by the transversely divided lobules, because nearly all
the changes in the liver produce disturbances in the
size, the shape, and the color of the lobules, and hence
these must be examined with particular reference to
any alterations. It is necessary to be able to recognize
the individual lobules and also to be able to distinguish
between their centre and periphery ; it may be stated
that if an hepatic vein be traced to its very commence-
ment, this point will correspond to the centre of a lobule
where the intralobular vein begins. As the blood
after death mainly collects in the hepatic veins and
adjacent capillaries it follows that the central portion
of the lobule is oftener darker in color than the
periphery; in the passive congestions of the liver this
144 The Technique of Post-Mortem Examination.
central dark red color becomes very marked, while in
fatty infiltration, for instance, the peripheral border of
the lobules may be light grey or yellow.
THE STOMICH AND THE DUODENUM.
The general size, the position, and the shape of the
stomach are easily made out while in situ.
Chronic adhesions about the gall bladder may
involve or cover up the duodenum so as to require
separation in order to bring its transverse and hori-
zontal portions into view.
Perforation of the stomach or the duodenum and
the effects thereof require a careful examination ; when
communications with adjacent organs have been estab-
lished, it will be well to remove these organs with the
stomach, deporting from the usual method of taking
out the organs to whatever extent may be necessary in
order to preserve the specimen as intact as possible.
In post-mortem gastro-malacia and rupture the
wall will present a softened, slimy appearance and a
variable quantity of stomach contents will be found
free in the peritoneal cavity in the vicinity of the
rupture, without any inflammatory changes in the
peritoneum, whereas perforation during life always
results in local or general peritonitis.
It is true that the contents and the mucous mem-
brane of the duodenum and the stomach can be fairly
well examined without removing the organs by contin-
uing the incision already made in the duodenum for
the purpose of exposing the biliary orifice upward to
the junction with the stomach; tJ ter o£ the
Examination of the Body. 145
pyloric opening may be estimated with the fingers or
measured with the cone — and then the stomach is
divided with the enterotome along the greater curv-
ature up to the fundus so that the contents may be
dipped out into a small cup, after which the division
is continued into the esophagus; in this way the con-
tents can certainly be closely enough inspected for
ordinary purposes, but a careful study of the mucous
lining demands the removal of the organs and nothing
in particular is gained by opening them in situ when
they are to be taken out. It would seem that the best
way to proceed would be to remove them at once in the
following manner:
Draw the lesser curvature downward and separate
its attachments ; dissect loose the lower end or as much
of the esophagus as desired, dividing the diaphragm
if necessary in order to free it fully, place a ligature
around and cut it across if that has not already been
done; then divide the structures along the greater
curvature and dissect loose the duodenum, the lower
end of which was ligated before removing the small
intestine. In many instances of disease of the head
of the pancreas resulting, perhaps, in its becoming
matted together with the duodenum it may be very
desirable to remove that organ at this time; otherwise
the pancreatic and the bile ducts are cut across as they
enter the wall of the descending duodenum.
The contents of the stomach may be collected by
letting them flow into a cup or graduate after removing
the ligature around the end of the esophagus or the
duodenum; through small incisions in the greater
10
146 The TBcHHionz of Post-Mobtkh Exauisation.
cnrratare the diameter of the cardiac and pyloric
orifices may be measured vith a cone and then an
incisioii is made with an enterotome from the esoph-
agUB along the greater cnrvatiirG and the whole length
of the daodennm, removing any ligatures in advance;
it is best to open the stomach along the greater curv-
ature because peptic ulcers and other lesions are ofteuest
found in the vicinity of the lesser curve.
It may be well to wash away from the mucosa any
adherent contents with a gentle stream of water; then
the quantity as well as the nature of the mucus present,
especially over the pyloric portion, may be noted; the
numerous ^"ariations in color presented by the gastric
mucosa must be accurately described and in the duo-
denum the extent of biliary discoloration must be
noticed.
It is to be recollected that thickening of the
gastric mucous membrane is to be determined by
examining its line of junction with the esophageal;
"Normally the lower, jagged edge of the esophageal
mucous membrane projects over that of the stomach;
when the latter is thickened this relation is changed,
so that both either occupy the same level, or the gastric
mucous membrane is the more prominent" Folds in
the mucosa caused by conti'action of the mnscular coot
disappear on stretching the walb in a vertical direction
to the folds, while folds due to hypertrophy remain after
such stretching.
Special morbid lesions, lor ^rffeneral, c
be looked for with all necear ^^fcyi™\ to •
details.
Examination of the Body. 147
THE PANCREAS.
The pancreas is now easily removed and after
being weighed, measured and inspected a longitudinal
incision may be made from head to tail, exposing the
interior; usually the excretory duct is easily found on
making this division and it may be further incised with
small scissors.
Diseases in the region of the gall bladder, the
duodenum, the pylorus and the pancreas often result in
such matting together and adhesions that it may be
necessary to remove these organs in conjunction in
order to examine the complicated conditions satisfac-
torily. In removing such masses care is to be used so
that the aorta and the vena cava are not damaged.
THE SEMILUNAR GANGLIA
" The semilunar ganglia of the solar plexus, two
in number, one on each side, are the largest ganglia in
the body." They are situated on each side of the celiac
axis and the superior mesenteric artery close to the
suprarenal capsules in connection with which they may
be removed. The ganglia lie upon the aorta just
below and in front of the aortic opening in the dia-
phragm and whe they coalesce to form a ganglionic
ring around the commencement of the celiac axis it is
known as the solar or celiac ganglion.
In cases of Addison's disease and in other
that render a thorough examination of those
the usual order may be changed to
'*> intestines, the liver, the stomach
3 removed while the adrenals, the
148 The Technique of Post-Mobtsm Examination.
kidneys and the pancreas are left in situ until the sym-
pathetic plexus and the semilunar ganglia have been
isolated and removed (Nauwerck).
AORTA, VENA CAVA, THORACIC DUCT, RETRO-
PERITONEAL GLANDS.
The mesentery is cut across at its root and then
the aorta and what remains of the vena cava will be
uncovered. The inferior vena cava and its large pelvic
branches are slit open along the anterior wall and the
contents as well as the walls examined; it is well to
commence from above where the vena cava was cut
across in removing the liver.
In case the thoracic duct is to be examined, this is
easiest while the retroperitoneal organs are in situ and
the aorta still intact The duct lies behind and to the
right of the aorta ; it may be looked for at its commence-
ment in the receptaculum chyli which lies upon the
first or second lumbar vertebra, also to the right of and
behind the aorta; at this point the right border of the
aorta may be elevated and the duct dissected free from
its beginning and upward, through the diaphragm,
into the thorax clear up to its termination at the junc-
tion of the left internal jugular and subclavian veins.
The duct may be slit open.
In many cases of acute general miliary tubercu-
losis as well as in cases of carcinoma in the abdomen
the somewhat delicate dissection of this duct will
certainly be necessary in order to obtain correct
information as to the generalization of the processes
mentioned.
Examination of the Body. 149
The aorta and its terminal branches may be re-
moyed intact or incised and examined in situ. In order
to remove it the upper end is seized and drawn forward,
being separated at the same time from its attachments
to the spine. The diameter of the vessel may be meas-
ured with cones previous to being opened; in adults it
should admit the forefinger or the thumb.
The aorta and its large branches may present a
number of important changes such as congenital
hypoplasia, advanced as well as limited artero-sclerosis,
aneurisms, thrombosis, etc; in the case of large aneur-
isms it may be necessary to remove the vessel in con-
nection with other organs.
The retroperitoneal lymph glands are examined
simultaneously with the aorta. The internal muscles
of the trunk, the diaphragm and the ilio-psoas can also
be investigated at this time.
The anterior surface of the spine and the pelvic
bones may require examination on account of malfor-
mation, deformity or disease. Portions of the spine
may be taken out and sawed through longitudinally
and the entire pelvis may be removed from the body
in the case of important pathological changes iu the
bones.
THE EXTREMITIES.
In the extremities the blood vessels, oerves, lymph
glands and vessels, the muscles, the bones, and the
joints may require examination in special cases ; usually
this examination is confined to those regions in which
changes are known or suspected to exist.
150 The Technique of Post-Mobtem Examination.
The location and the coarse of the incisions em-
ployed for the purpose of exposing or isolating any of
the structures just mentioned are in the main deter-
mined by the anatomic conditions; occasionally it
may be necessary to conceal the cuts as much as
possible. The nerves and the vessels are isolated in
practically the same manner as a dissection is made;
the larger structures are readily found in those parts
of their course that bring them nearest the surface.
The size, color and consistency of the muscles, are
readily noted; local and special morbid conditions
demand careful consideration.
In opening the joints the familiar incisions used
in ex-articulations and resection will answer very well ;
the condition of the capsule and of the ligaments is
usually readily determined in that way; suspected per-
forations of the capsule must be cautiously explored.
When the joint has been fully opened, the contents and
synovial membrane as well as the articular ends of the
bones, the size of the joint cavity, etc., can be studied
with all requisite attention to detail.
In order to thoroughly and completely examine a
bone it is necessary to remove it in toto or in part and
divide it longitudinally or otherwise with a saw, so
that the periosteum, the bone tissue proper, and the
marrow may be studied. Alterations in the size, shape,
color, and consistency of a bone demand detailed study;
fractures and displacements require careful dissection.
In malignant tumors with metastases, in general
miliary tuberculosis, in syphilis the osseous system is
not infrequently involved; in such cases the examina-
Examination of the Body. 151
tion of one long bone usually answers the purpose, and
the bone most frequently selected is one of the femora,
which can be removed from the body through an incision
in the course of the large femoral vessels. The bone is
placed in a vise and divided longitudinally by means
of a saw in the direction of the neck; the sternum can
also be readily sawed in two lengthwise.
In children that are presumably rachitic or sus-
pected of syphilis the line of ossification at the various
epiphyses may show very marked changes from the
normal.
The bony marrow being so frequently the seat of
morbid processes, it is necessary to bear in mind that
it also varies in appearance in the young and old.
In the young the marrow of all bones is red; after
puberty the red color is retained in the flat bones only,
while in the long bones it becomes yellow; under many
circumstances a reversion to the red variety occurs in
consequence of various pathologic changes.
EXAMINATION IN CASES OF SUSPECTED
POISONING.
Cases of suspected poisoning demand separate
consideration because they require a special method
of examination on account of their medico-legal
importance.
In order to preserve the organs and fluids from
such cases in proper condition for chemical analysis a
number of new, glass-stoppered jars and bottles, thor-
oughly washed, then rinsed with sulphuric acid and
finally with distilled water, should be at hand. As the
organs are placed in the jars, these should be sealed at
once and labelled. If they can be delivered to the
chemist immediately, then it is unnecessary to add
any alcohol; if they are be kept for a time or sent
quite a distance, then a sufficient quantity of strong
alcohol is to be added. A quantity of the alcohol used
is to be poured into a clean bottle, which is then sealed
and labelled and sent with the organs ; this is done in
order • that the chemical examination may show the
alcohol to be free of poison.
While these organs remain in the hands of the
physician he must keep them under sealed lock and
key so that he can swear, if necessary, that no poison
was added or the material in any way tampered with
while they were under his care. Such jars should
only be . delivered to some properly authorized person,
and an accurate record of the number, the contents,
152
Examination in Cases of Suspected Poisoning. 153
the seal, aud the disposition of the jars and bottles
should be made on the spot and kept for future refer-
ence.
What organs and fluids should be preserved will
depend largely on circumstances and upon what the
particular poison suspected may be. The stomach,
the intestines with contents, the liver, the brain,
should always be preserved. In the case of diffusible
poisons, strychnine, arsenic, etc., the urine should be
drawn into a new, clean bottle with a clean catheter;
and, in addition to the stomach and intestines with
contents, every internal organ with a mass of muscular
tissue and a large piece of bone should be kept for the
purpose of furnishing the chemist with sufficient
material to make the results of the analysis as positive
as possible.
A portion of the blood should be kept in those
cases in which spectrum analysis may be supposed to
furnish important information.
The organs and tissues are subjected to the same
general examination as imder ordinary circumstances
before they are placed in the jars, but much caution
must be used not to bring them in contact with any
possibly poisonous substances.
When poisoning is suspected the section com-
mences with the abdominal cavity, the position and the
fullness, color and smell of the stomach and other
abdominal organs being carefully noted. Then a
double ligature is placed around the lower end of
the esophagus immediately above its junction with
the stomach; the duodenum is tied in two places
154 The Technique of Post-Mobtem Examination.
in the same way, the ligatures being placed at a safe
distance from each other so that they will not slip; then
the stomach is removed, the duodenal ligature is cut
and the end of the duodenum placed in a wide jar; by
raising the cardiac end the stomach will empty itself
into the jar.
In order to study the effects of corrosive poison
the esophagus may be taken out with the stomach after
having removed the other organs of the neck and placed
a good ligature around the upper end; the contents can
be emptied as before and then the incision opening the
esophagus may be carried along the greater curvature
out through the duodenum.
The small intestine may be removed, and the con-
tents emptied into another jar or bottle and the large
intestine can be treated likewise.
The examination of the digestive tract is done as
early as possible in these cases in order that the con-
tents may be preserved without admixture and in order
to avoid the liability of injury to the stomach and the
intestines that follows if they were to be examined in
the usual order, so that everything can be placed at the
disposal of the law under as favorable circumstances as
possible.
On account of the likelihood that some of the con-
tents of the stomach and intestines will cling to the
mucous membrane after they are emptied, it is best
to preserve these organs by themselves. With reference
to the other organs it cannot be said to be necessary to
preserve each single organ or set of organs by them-
selves, although that would be the best plan.
Examination in Cases of Suspected Poisoning. 155
In case trichinoBis is suspected the contents of the
upper part of the small intestine must be subjected to
careful microscopic examination and specimens are to
be taken from the intercostal and cervical muscles and
the diaphragm.
EXAMINATION OF NEW-BORN CHILDREN.
" 111 examining the bodies of new-bom children we
may have to determine, besides the ordinary lesions of
disease, the age of the child, whether it was born alive,
how long it has been dead, what was the cause of
death."
The examination differs from the ordinary tech-
nique in the following respects:
I. Inspection, The external examination of the
new-born involves a number of points which bear
directly upon the age and the length of time that has
elapsed since the birth of the child.
For a detailed description of the fetus during the
different months of pregnancy reference is made to
works on obstetrics.
The following table shows the weight and the
length of the fetus at each month of gestation
(v.Hecker cited by Nauwerck) :
Second month .... Weight 4gr . . .
Third month " 5-20gr...
120gr...
284gr...
634gr . . .
12L8gr...
1549gr . . .
1971gr...
2334gr . . .
From the fifth month the age in months can be
determined by dividing the length in centimeters by five.
Fourth month .... **
Fifth month "
Sixth month "
Seventh month . . .
Eighth month ....
Ninth month "
Tenth month "
((
((
Length 2. 5 — 3 cm.
7 — 9 cm.
10—17 cm.
18—27 cm.
28—34 cm.
35—38 cm.
39—41 cm.
42 — 44 cm.
45 — 47 cm.
156
EsAMiNiTios OF New-Bokn Children. 157
The pupillary membrane disappears iii the eighth
mouth.
At full term the skin is quite firm and white;
the lanugo is found chiefly nn the shoulders; the
umbilicus is situated a little below the centre of the
body: the cartilages in the nose and the ears are quite
firm; the nails reach beyond the ends of the fingers but
not beyond the ends of the toea ; the labia are nearly
always closed and both testicles should occupy the
scrotum.
I lentfth and the weight the fol-
■ tekou (at term the results
Examination of New -Born Children. 159
increases from the third to the fourth. The umbilical
cord soon begins to shrivel, becomes brownish-red in
color, and after three or four days the skin around its
attachment becomes red; the end of the cord should be
closely inspected to see whether it is cut or torn; a
partially or wholly cicatrized navel, or redness, swelling
and suppuration about the insertion of the still attached
cord is a positive indication that the child has lived
several days.
Finally, the whole body is looked over for marks
of violence, blood, signs of decomposition, etc., and the
mouth and nose are examined for foreign substances.
II. The Spinal Canal. In opening this canal the
vertebral arches may be cut across with scissors.
(Nauwerck.)
III. The Head, The incision and deflection of the
soft parts is made exactly as in adults. The margins
of the bones of the skull are then separated from their
attachment to the dura in the following manner: make
a small opening in the centre of the anterior fontanelle
and incise the longitudinal inus with scissors through-
out its whole extent; then divide the dura on each
side of the sinus; cut through the dura with strong
scissors along the coronal and lambdoidal sutures on
each side, carefully avoiding the surface of the brain.
The bones of the skull can be drawn away from the
brain and cut through around the greatest circumfer-
ence of the skull. The brain can now be removed as
in the adult.
On account of the softness of the brain in children
and the firmness of the adhesions between the dura and
100 The Tbobsioue of Post-Mobtem Examination.
the bones along the sutures it may be very difficult to
succeed in removiDg the brain from a child without
some injury. If it is not desired to preserve the brain
as a whole, then Griesinger^s method of sawing directly
through the skull and the brain at the same time may
be used to very good advantage; the skull cap receives
the upper part of each hemisphere and the remainder
of the brain is easily removed in the ordinary way
(Pig 39).
IV. The Abdomen. The umbilical vessels maybe
examined in the following manner: The usual incision
is made from the chin downward in the median line; &
short distance above the umbilicus thia cut divides into
two divei'ging incisions which extend to the pubes.
The abdomen is opened in the lines thus mapped out
and the triangular £ap in the abdominal wall is raised
Examination of New-Bokn Ghildben. 161
up by traction on the cord or at the naveL This
brings the umbilical vein into prominence, its course to
the liver can be followed and it may be opned with £z:e
scissors; the vein can be ligated and divided, ai^i iz.^
flap turned down over the pubes. The tiivergii:^ izi-
bilical arteries are now readilv seen on estch siLr zi zJir:
remains of the urachus, and they can h^ operseii -rriii
fine scissors also ( Nauwerck i i Fig. 4*> .
V. The Chest. The ductus arc-erL«:'&Ti? L? ?■•*«; *iaair-
ined while in situ. The thvmus is ir^z r'riiii-^'Tfi •nirtu
the right ventricle is incised along "Jik: ^cnriui im:
the incision extended into the ntdnn'^narr ijvir' la.a^r
the middle of its anterior w^iIL Tie :!^Jil!^r ;i: -:ii*
ductus arteriosus is sitaau«r»i b*=:trwr«L izii \#*^" jn: "Mi
two openings of the right ar.«i lin^ j*c: :u.:ui;!i;i;—
branches; a smaU sound •agtn he Tm»f»ei -:ii--iiai:i in-
duct into the aorta, taarrr-g i iirr«io:rL ft:nri-v il-: hl-: ^
little to the left.
The foramen ot*;:^ ri^sirvren "rjir: *▼: i^ii-iv*-:- -
readily found.
In order to di^femiiiT "rLsd:*?? r*js:inr:j:n. :-&-
taken place the fc>!l>T2ig jr=>!et:i:r»: it THi-iaJl7 l'Aj:»r ^r:
1. The condhsKiSi of ick: fi5«cc:riezL i% 'j?r,ffr:z:j::u^\
before the chest i* fi^^^jjec: inj?fL TrfirxrxrdxXL L« f.;. . ;
taken place the diApLnigs:; z^iSkjija^ w ti**: ffii :? •^-rr.:,
rib, otherwise to tte fooni '.*i}t,
2. The traehiM is io be ]£gSK*i ii. liii*: z«v;a: -^jt*:
opening the chest
3. Open the cL*g!t esThj. erioici**: tii^e litr^nsi..
pericardium, and be&rL
11
162 The Technique op Post-Mortem Examination.
4. Open and examine pharynx, larynx and trachea
above the ligature.
5. Remove the organs from the chest in toto,
dividing the trachea above the ligature.
fi. Separate the heart and the thymus gland and
then place the lungs in a basin of clean, cold water and
note whether they sink or float.
7. Incise the lungs, notice whether they crepitate
or not, and whether air bubbles appear when portions
are compressed below the surface of the water.
8. Divide the lungs into lobes and the lobes into
small pieces and apply the hydrostatic test.
9. In the case of decomposition and the possible
development in this way of sufficient gas in the lungs
to buoy them up in the water, a number of small pieces
from the lungs are to be placed between the folds of a
towel, which is then thorougly compressed between two
flat surfaces, such as between a board and the floor by
standing on the board. The gas due to decomposition
IS pressed out and the pieces from atelectatic but decom-
posed lungs will consequently sink when thrown in water
after this treatment; inspired air, on the other hand,
cannot be pressed out and the pieces from inflated
lungs will continue to float.
It is to be borne in mind that the hydrostatic test
only determines whether a child has or has not breathed.
The presence of gas in the digestive tract usually
indicates extra-uterine deglutition. Portions of the
digestive tract may be ligated and subjected to the
hydrostatic test. Decomposition can cause the develop-
ment of gas here also.
Examination of New-Born Childben. 163
Average Weight of Organs at Full Term,
Brain 380 gr.
Heart 20.6 gr.
Liver 128 gr.
Lungs 55 gr.
Kidneys 23.5 gr.
Spleen 11 gr.
Thymus 14 gr.
RESTORATION OF THE BODY.
On completing the examination the body cavities
should be sponged dry and the organs returned as near
as possible to their respective places. The brain is
usually placed in the thorax because it is rather
difficult to force it all back into the cranial cavity,
which had best be filled with absorbent cotton or
sawdust and shavings (excelsior packing) or a sandbag
so as to prevent bloody fluid from oozing out through
the incisions.
In all private post-mortem examinations it is quite
important to secure the skull-cap in its normal position
so that the unsightly disfigurement, which results
from its sliding backward and from side to side,
may be avoided. Sutui'es through the divided temporal
muscles and fasciae on each side will generally hold the
calvaria in place quite nicely if a good hold in the
fasciae is secured"; sutures can also be passed through
drill holes in the skull ; double-ended tacks can also be
used for this purpose; finally the plan advocated by
Slee* may be mentioned: allow the usual saw-cuts to
cross each other a little above and behind each ear so
that slits about an inch long are formed in the temporal
bones (Fig. 41); an ordinary roller bandage is now
stretched across the skull and crowded edgewise into
the slits; the calvaria is replaced and the extremities
*Medical News, 1892.
164
BeSTOSATIOX UK TUX liui't
are bronght over the vaalt ami fjrml v ni.>-<iti <l It^
or by pina.
After aecaiing the Hkull-i^up tin' »• iil|. i^
with the glover's stitch ai]<] tli<; imii umaiifl >
cover the iacisioii.
It may Ij*: wivitinhi': i; JilJ tf,. -Ij. ,-l 'uvjl^
some packing m^V^ml ju -yfJ';) Vj m>.'1/>h: llo: Ji'iimiil
shape and fulliii^ib of lij': ih'fiui^ t^^f'Ti ::'jt>jritif{ lln:
long anterior iii':i)-j<>jj.
WJien thfe iHOulli Jwti: lyMrn iun-'-A '»|<':)i mii'I tJm
tongue removfefl witji tij'^ 'truhuti of iIj'j /(Uck, Uks IIjih
may >>e united wit)j a wrri'ih of Hutun^ij jwKKfed througli
the oral mncouB jaimhraTin.
166 The Technique of Post-Mortem Examination.
The incisions at the pelvic outlet must be securely
sutured; the pelvic cavity should be packed with cotton
or similar material to prevent leakage.
In the place of bones that have been removed
suitably formed pieces of wood may be inserted, and
such pieces may be retained by means of wire or heavy
cord passed through drill-holes.
The suture employed in closing cutaneous post-
mortem incisions is inserted through the skin only,
with a good sized curved needle, and each margin of
the incision is perforated in turn from without inward
so that the closure can be made quite tight after the
manner of the glover's stitch; the ends of the thread
(Barbour's linen thread No. 25) must be securely tied
at the beginning and end of the suture.
Finally the exterior of the body is thoroughly
cleansed.
INDEX.
Paos
Abdomen, inspection of »4
Adrenals, RemoYal of 120
Weight and Dimensions of 29
Alcohol for fixing 18
Anterior Incision, The Long 80
Aorta, Examination of 149
Removal of 149
Bi
^ILE DUCT, Common, Examination of 189
Bladder, Removal of 127
Body, Examination of 88
In cases of Saspected Poisoning 152
Embalmed 5
Frozen 6
Inspection of 38
Internal Examination of 48
Restoration of 164
Bottles and Jars 37
Brain, Examination of 58, 62
Meynert^s Method of Sectioning 71
Pitres-Hamilton Method of Sectioning , 68
Removal of 68
Virchow's Method of Sectioning 63
Weight and Dimensions of 29
Broad Ligaments, Examination of 132
Brnnetti^s Chisels 47
C
I AMERA 37
Chest, Inspection of 87
Opening the 86
Children, New-born, Examination of 166 et seq.
Chisels 33, 47
167
168 Index.
Paok
Coronary Arteries, Inspection of 90
Cranial Cavity, Examination of Coverings of 51
Culture Media 37
D
'EATH,Time after for Autopsy 4
Dissection Wounds 26
Duodenum, Examination of 144
Removal of 146
E
ARS, Examination of 76
Embalmed Bodies 5
Examination of Aorta 149
Base of Skull 76
Body 38
Body in suspected Poisoning 162
Brain 68, 62
Broad Ligaments 132
Common Bile Duct 189
Coverings of Cranial Cavity 61
Duodenum 144
Ears 76
Extremities 149 et seq.
Face 80
Gall Bladder 141
Intestines 137, 138
Kidneys 122
Liver 141
Lungs 107
Mesentery 134
Nasal Cavities 78
New-born Children 166 et seq.
Omentum 118
Orbits 76
Pancreas 147
Peritoneum 119
Portal Vein 139
Prostate 130
Rectum 133
Retroperitoneal Glands 149
ExaminAtioii of Semflnnar Gmnglia 14T
Spermatic Cord 1310
Spinal Canal i*^
Spinal Cord snd Column 4$
Spleen lli»
Stomach 144
Testicles 1310
Trachea 110, 11*% 114
Uterus 1311
Vaf^a IHl
Vena Cava 148
Vnlva 181
Extremities. Examination of 149
r ACE, Examination of 80
Flemming*8 Solution 20
Forceps 83
Frozen Bodies ft
VJ ALL BLADDER, Examination of 141
Removal of 141
Ganglia, Semilanar, Examination and Removal of 147
llEART, Inspection of *M)
Opening of i)l, KK)
Removal of *. \)S vt sotf
Weight and Dimeosions of 21)
Hydrostatic Test of Lnngs 102
Inspection of Abdomen 84
of Body m
of Chest Cavity 87
Intestines, Examination of 1H7
Removal of 1JJ4
iXIDNEYS, Examination of 122
Removal of 1 lU
Weight and Dimensions of 2J)
Knives JJI
170 Index.
Paok
Liver, Examination of 141
Removal of 141
Weight and Dimensions of 29
Liyores Mortis 89
Loot's Rhaohitome 46
Lungs, Examination of 107
Hydrostatic Test of 162
Inspection of 106
Removal of 106, 116
Weight and Dimensions of 29
M,
ALLET 33
Measures 33, 35
Mesentery, Examination of 134
Meynert's Method of Brain Sectioning 71
Microscope 35
Microtome 35
Mailer's Fluid for Fixing 19
Myelotom, Pick's 59
N.
1 ASAL CAVITIES, Examination of 78
Nerve Sympathetic, Examination of Ill
New-born Children, Examination of 156 et seq.
0=
'MENTUM, Examination of 118
Orbits, Examination of 76
Ovaries, Removal of 129
Weight and Dimensions of 29
P,
ANCREAS, Examination of 147
Removal of 147
Weight and Dimensions of 147
Pericardium, Inspection of 88
Opening of 89
Peritoneum, Examination of 119
Pick's Myelotom 59
Pitres-Hamilton Method of Brain Section 68
PleursB, Inspection of 87
Removal of 106
Index. 171
Paok
Poisoning, Examination in CaseB of Suspected 152
Portal Vein, Examination of 189
Fost-Mortem Instruments 80
Wounds 26
Preparation of Material for Baoteriologic Purposes 15
Microscopic Purposes 15
Probes 38
Prostate, Examination and RemoYal of 180
Weight and Dimensions of 29
lyECORD of Autopsies, Nature of 7
Rectum, Examination of 183
Removal of Adrenals 120
Aorta 149
Bladder 127
Brain 68
Gall Bladder 141
Heart 93 ef seq.
Intestines 134
Kidneys 119, 120
Liver r 141
Organs of Hearing 78
Pancreas 147
Reotnm 127
Semilunar Ganglia 147
Skull Cap 58
Spinal Cord 48, 49
Spleen 119
Stomach 146
Tongue 112
Trachea 110, 112, 116
Urethra 129
Vena Cava 148
Report of Autopsy, Sample of 13
Bestoration of Body after Autopsy 164
Retroperitoneal Glands, Examination of 148
Rhachitome, Luer's 46
Rigor Mortis 39
Room for Autopsies 2
172 Index.
Paqe
O AWS 33
Scales 36
Scissors 31
Semilunar Ganglia, Examination of 147
Skull, Examination of Base of 76
Skull Cap, Removal of 63
Smear Cultures 22
Spermatic Cord, Examinaton of 130
Spinal Canal, Examination of 46
Cord, Examination of 48
Weight and Dimensions of 30
Spleen, Examination of 1 19
Removal of 119
Weight and Dimensions of 29
Stomach, Examination of 144
Removal of 146
Weight of 30
T
ABLE for Autopsies 2
Testicles, Examination of 130
Weight of 30
Thyroid, Examination of 116
Weight and Dimensions of 30
Time after Death for Autopsies 4
Tongue, Removal of 112
Trachea, Examination of 110, 113
Removal of 110, 112, 116
Treatment of Post-mortem Wounds 28
Tube Cultures 24
U
RETHRA, Removal of 129
Uterus, Examination of 131
Uterus, Weight and Dimensions of 30
V.
AGINA, Examination of 131
Vena Cava, Examination of 148
Removal of 148
Virchow's Method of Brain Section 63
Vulva, Examination of 131
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cine in the College of Eclectic Medicine and Surgery, Atlanta, Georgia;
Member of the National Eclectic Association, and of the Eclectic Medical
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The Practice of Medicine, or. The Specific Art of Healing.
New Edition. One volame, 8vo., xxiv-|-667 pages.
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HEKTOEN, L.J
Pathologist to the Ck>ok Ooaaty Hospital, Chicago.
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LYDSTON (G. FRANK), M. D.,
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of the Oenlto-Urinary and Venereal Department of the West Side Dispensa-
tory; Fellow of the Chicago Academy of Sciences, and of the Southern
Surgical and Gynoecologioal Association.
Stricture of the Urethra. One volume, 8vo., 330 pages.
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Varicocele and its Treatment. One volume, 12mo., 128 pages.
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LYMAN (HENRY M.), A. M., M. D.,
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Insomnia and Other Disorders of Sleep. One volume, l2mo.,
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MARTIN (F. H.), M. I).,
Professor of GynaBcology at the Post-Oraduate Medical School, Chicago;
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aod Post-Oraduate Hospitals; Member of the American Oynascological So-
ciety, and the Chicago Gynaecological Society, etc., etc.
Electricity in the Diseases of Women and Obstetrics. One
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MITCHELL (CLIFFORD), A. M., M. D.,
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A Clinical Study of Diseases of the Kidneys. Including
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MITCHELL (CLIFFORD), A. M., M. D.,
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Dental Chemistry and Metallurgy. Being the Third Edition
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• • •
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OLDBERG (OSCAR), PHiRM. D.,
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Northwestern University School of Pharmacy; Member of Committee
for Revision of the Pharmacopoeia of the United States.
A Mannal of Weights and Measures. iDcluding principles
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pages. Cloth, tl.50 net.
*^* The adoption of the metric system in the new (1890)
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OLDBERG (OSCAR), PHARM. I).,
An Ontline of a Coarse of Stndy in Practical Pharmacy.
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PARREIDT, JUL.,
Dental Surgeon to the Surgical Policlinic at the Institute of the University
of Leipsic.
A Compendium of Dentistry. For the use of medical practi-
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PARKES (CHARLES T.), A. M., M. D.,
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iv
THE WORKS OF NICUOLAS SENN, PH. D., M. D.,
Professor of Practice of Surgery and Olinical Surgery in Bush Medical
College; Attending Surgeon Presbyterian Hospital.
I. Experimental Surgery. Contento— B'raotures of the Neok
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Oapsnlar Fracture. II. Experimental Researches on Cicatrization
in Blood Vessels after Ligature. III. An experimental and clinical
volume, and their reciprocal relations; weighing and measuring;
study of Air-Embolism. IV. The Surgery of the Pancreas, as based
upon experiments and olinical researches. V. An experimental
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Treatment of Intestinal Obstruction. VI. Rectal Insufflation of
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convenient sized volume, carefully indexed.
II. Intestinal Surgery. Contents— The Surgical Treatment
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Intestinal Surgery, with special reference to the treatment of Intes*
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Infallible Test in the Diagnosis of Visceral Injury of the Gastro-
intestinal Canal in Penetrating Wounds of the Abdomen. IV.
Report of Cases. One handsome volume, 8vo. Cloth, t2.50.
*^ The most striking, the most valuable of Sennas original conceptions and
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2. Lateral approximation by decalcified bone plates.
3. The application of omental grafts in abdominal surgery; and
4. The mechanical irritation of peritoneal flurfaces between which it is
desired that adhesion should take place.
The greatest value of Benn's work is its suggestiveness. He has set surgeons
in all countries to thinking and planning. His methods as such may none of them
be permanent, but he ha» given an impetus to abdominal surgery Uie outcome of
which none can foresee, but which is full of promise. He is in the very van of
progress, a leader who is not infallible, but who has earned by hard work and
ability the enviable place the holds in the scientific world. ^^—77i« American Journal
of Medical Science.
HARLAN (A. W.), DD. S., M. D.,
A Register for Recording Operations on the Natural Teeth.
A simple and complete method for keeping accounts of dentists.
One volume, oblong (9}^xl2 inches), bound in half Russia, round
corners. Prices, 360 pages, |3.50; 600 pages, $4.60, net. Each with
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THE UNIVERSAL LIQUOR REGISTER.
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LANE MEDICAL LIBRARY
To avoid fine, this book should be returned on
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J57 Hektoen, L. S0065
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